Deficiencies (last 4 years)
Deficiencies (over 4 years)
26 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
364% worse than Connecticut average
Connecticut average: 5.6 deficiencies/yearDeficiencies per year
80
60
40
20
0
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Nov 13, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding an allegation of verbal abuse by a nurse aide towards a resident dependent on staff for personal care.
Complaint Details
The complaint investigation substantiated verbal abuse by Nurse Aide #1 towards Resident #1 on 8/27/25. The facility removed the nurse aide and informed the staffing agency. The facility did not notify law enforcement because the abuse was verbal, not physical, despite policy requiring notification within two hours if abuse is alleged.
Findings
The facility substantiated the allegation that a nurse aide verbally abused Resident #1 by yelling and aggressive behavior during care. The nurse aide was removed from the facility and the staffing agency was informed they would no longer employ the aide. The facility failed to timely report the verbal abuse allegation to law enforcement as required by policy.
Deficiencies (2)
Failure to protect residents from verbal abuse by staff.
Failure to timely report suspected verbal abuse to law enforcement.
Report Facts
Residents sampled: 3
Date of incident: Aug 27, 2025
Date of survey completion: Nov 13, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #1 | Nursing Supervisor | Witnessed and responded to verbal abuse incident |
| Licensed Practical Nurse #1 | Charge Nurse | Witnessed verbal abuse and reported incident |
| Licensed Practical Nurse #2 | Charge Nurse | Witnessed verbal abuse incident |
| Nurse Aide #1 | Nurse Aide | Alleged perpetrator of verbal abuse |
| Assistant Director of Nursing | Assistant Director of Nursing | Conducted investigation and substantiated verbal abuse |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Nov 13, 2025
Visit Reason
The inspection was conducted in response to a complaint alleging verbal abuse by a nurse aide toward a resident dependent on staff for personal care.
Complaint Details
The complaint investigation involved Resident #1 who was verbally abused by Nurse Aide #1 on 8/27/25. The facility substantiated the verbal abuse allegation after interviews and review of documentation. The nurse aide was removed from the facility and the staffing agency was notified. The facility did not notify law enforcement timely because the abuse was verbal, not physical.
Findings
The facility substantiated the allegation that a nurse aide verbally abused Resident #1 by yelling and aggressively gesturing during care. The nurse aide was removed from the facility and the staffing agency was informed that the aide would no longer be employed. The facility failed to timely report the verbal abuse allegation to law enforcement.
Deficiencies (2)
F 0600: The facility failed to protect Resident #1 from verbal abuse by a nurse aide who yelled and aggressively gestured at the resident during care. The nurse aide was removed pending investigation and was no longer employed by the staffing agency.
F 0609: The facility failed to timely report the allegation of verbal abuse to law enforcement as required by policy. The facility substantiated the verbal abuse but did not notify law enforcement because there was no physical abuse evidence.
Report Facts
Residents sampled: 3
Resident involved: 1
Date of incident: Aug 27, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Witnessed nurse aide yelling and reported incident |
| LPN #2 | Licensed Practical Nurse | Heard yelling and responded to resident's room |
| RN #1 | Registered Nurse | Nursing supervisor called to incident and conducted investigation |
| NA #1 | Nurse Aide | Alleged to have verbally abused Resident #1 and removed from facility |
| Assistant Director of Nursing | Assistant Director of Nursing | Conducted investigation and substantiated verbal abuse allegation |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Aug 27, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to provide adequate supervision to prevent a resident identified at risk for wandering from leaving the facility without staff knowledge.
Complaint Details
The complaint investigation found that Resident #1, identified as an elopement risk, left the facility multiple times without staff preventing the exit. The security guard deactivated the wander guard alarm without notifying nursing staff, allowing the resident to leave. The facility did not have a wander guard policy in place.
Findings
The facility failed to ensure adequate supervision of Resident #1, who was identified as an elopement risk and left the building multiple times without proper staff intervention. The security guard deactivated the wander guard alarm allowing the resident to leave, and the facility lacked a formal wander guard policy.
Deficiencies (1)
Failure to provide adequate supervision to prevent a resident at risk for wandering from leaving the facility without staff knowledge.
Report Facts
Dates of incidents: 3
BIMS score: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| SG #1 | Security Guard | Deactivated wander guard alarm allowing Resident #1 to leave the facility |
| LPN #1 | Licensed Practical Nurse | Observed Resident #1 leaving the assisted living facility and notified security |
| ADNS | Assistant Director of Nursing Services | Interviewed regarding facility policies and security guard actions |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Aug 27, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to provide adequate supervision to a resident identified at risk for wandering, who was able to leave the facility without staff knowledge.
Complaint Details
The complaint investigation involved Resident #1, who was identified as an elopement risk and left the facility multiple times without proper supervision. The security guard deactivated the wander guard alarm allowing the resident to exit. The facility did not have a wander guard policy in place. The complaint was substantiated based on the findings.
Findings
The facility failed to prevent a resident at risk for wandering from leaving the building without staff knowledge. The security guard deactivated the wander guard alarm allowing the resident to exit, and the facility lacked a wander guard policy despite having an elopement risk resident.
Deficiencies (1)
F 0689: The facility failed to ensure that a nursing home area was free from accident hazards and did not provide adequate supervision to prevent a resident at risk for wandering from leaving the facility without staff knowledge.
Report Facts
BIMS score: 14
Date of facility reportable event: Jul 15, 2025
Date of physician's order: Jul 15, 2025
Date of facility reportable event: Aug 2, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| SG #1 | Security Guard | Deactivated wander guard alarm allowing Resident #1 to leave the facility |
| LPN #1 | Licensed Practical Nurse | Observed Resident #1 leaving and notified security |
| NA #1 | Nurse Aide | Last saw Resident #1 on the unit before elopement |
| NA #2 | Nurse Aide | Observed Resident #1 returning and assisted in escorting back |
| ADNS | Assistant Director of Nursing Services | Interviewed regarding the incident and facility policies |
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Jun 6, 2025
Visit Reason
The inspection was conducted as an annual survey to assess compliance with care standards, focusing on incontinent care for residents requiring assistance with personal hygiene.
Findings
The facility failed to ensure that two sampled residents who were incontinent of bowel and bladder received incontinent care as documented in their care plans. Documentation gaps and inadequate care were noted, resulting in residents being found on soiled linens and briefs.
Deficiencies (1)
Failure to provide incontinent care every two hours as required by the care plan, resulting in residents being found on soiled linens and briefs.
Report Facts
Residents sampled: 3
Residents affected: 2
Date of deficient care documentation: Apr 14, 2025
Date of disciplinary action policy: Apr 15, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Aide #1 | Nurse Aide | Assigned nurse aide for 7AM-3PM shift who received written disciplinary action |
| Nurse Aide #2 | Nurse Aide | Reported residents found on soiled linens to Director of Nursing |
| Director of Nursing | Director of Nursing (DON) | Initiated disciplinary action and interviewed regarding incontinent care failures |
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Jun 6, 2025
Visit Reason
The inspection was conducted as part of the annual survey to assess compliance with care standards, focusing on incontinent care for residents requiring assistance.
Findings
The facility failed to ensure that residents who were incontinent of bowel and bladder received timely and adequate incontinent care as documented in their care plans. Documentation gaps and failure to provide care every two hours were noted, leading to residents being found on soiled linens.
Deficiencies (1)
F 0677: The facility failed to provide incontinent care every two hours as required by the care plan for residents incontinent of bowel and bladder. Documentation showed missed care during the 7AM-3PM shift and residents were found lying on soiled linens.
Report Facts
Residents sampled: 3
Residents affected: 2
Date of care plan revision: Apr 9, 2025
Date of care plan: Mar 12, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Initiated disciplinary action and provided interviews regarding incontinent care failures | |
| Nurse Aide #1 | Assigned to 7AM-3PM shift, received disciplinary action for failure to provide incontinent care | |
| Nurse Aide #2 | Reported incontinent care failures to Director of Nursing |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Apr 11, 2025
Visit Reason
The inspection was conducted following complaints from two residents (Resident #1 and Resident #2) alleging neglect by a nurse aide who failed to provide incontinent care overnight on 3/20-3/21/25.
Complaint Details
The complaint investigation substantiated neglect by Nurse Aide #1 who failed to provide incontinent care to Residents #1 and #2 overnight on 3/20-3/21/25. Resident statements, nurse notes, and facility incident reports confirmed the neglect. Nurse Aide #1 denied allegations but was suspended and terminated following the investigation.
Findings
The investigation found that Nurse Aide #1 neglected to provide incontinent care to the two residents overnight as alleged, with documentation confirming lack of care from late evening to morning. The nurse aide was suspended and subsequently terminated due to a pattern of neglect.
Deficiencies (1)
Failure to ensure residents were not neglected by a nurse aide and were provided appropriate incontinent care.
Report Facts
Residents affected: 2
Date of neglect incident: Mar 20, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NA #1 | Nurse Aide | Named in neglect findings for failure to provide incontinent care to residents. |
| Assistant Director of Nursing | ADON | Interviewed regarding the investigation and reported suspension and termination of NA #1. |
| 7AM-3PM charge nurse | Reported complaints from Resident #2 and provided written statement about neglect. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Apr 11, 2025
Visit Reason
The inspection was conducted following complaints from two residents alleging neglect by a nurse aide who failed to provide incontinent care overnight.
Complaint Details
The complaint investigation substantiated that Nurse Aide #1 neglected Residents #1 and #2 by failing to provide incontinent care overnight on 3/20-3/21/25. Resident statements, nurse notes, and facility incident reports confirmed the neglect. Nurse Aide #1 denied the allegations but was suspended and subsequently terminated following the investigation.
Findings
The investigation found that Nurse Aide #1 neglected to provide incontinent care to Residents #1 and #2 overnight on 3/20-3/21/25. The facility confirmed the neglect through resident interviews, documentation review, and staff statements, resulting in the termination of Nurse Aide #1.
Deficiencies (1)
F 0600: The facility failed to protect residents from neglect by a nurse aide who did not provide incontinent care to two residents overnight as required by their care plans.
Report Facts
Date of survey completion: Apr 11, 2025
Date of neglect incident: Mar 20, 2025
Date of neglect incident: Mar 21, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NA #1 | Nurse Aide | Named in neglect findings for failing to provide incontinent care to residents |
| Assistant Director of Nursing | ADON | Interviewed regarding the neglect investigation and facility actions |
| 7AM-3PM charge nurse | Reported complaints from Resident #2 and provided statements about neglect |
Inspection Report
Routine
Deficiencies: 15
Date: Feb 25, 2025
Visit Reason
Routine inspection of Mary Wade Home nursing facility to assess compliance with regulatory requirements including resident care, safety, infection control, and staff training.
Findings
The facility had multiple deficiencies including failure to maintain resident dignity, inadequate supervision to prevent elopement, incomplete care plans, failure to follow pressure ulcer care plans, inadequate feeding supervision, improper medication storage practices, failure to maintain food safety temperatures, and incomplete staff training documentation.
Deficiencies (15)
F 0550: The facility failed to maintain dignity for a resident with a urinary catheter drainage bag by not properly covering the drainage bag, exposing urine to public view.
F 0603: The facility failed to ensure residents who did not meet clinical criteria to reside on a locked unit were provided with a method of opening doors independently, restricting resident movement unnecessarily.
F 0604: The facility failed to keep a resident free from physical restraint during medication administration despite an allegation of abuse.
F 0656: The facility failed to develop a comprehensive care plan for a resident at risk for elopement, omitting elopement risk identification and precautions.
F 0657: The facility failed to revise resident care plans for oxygen therapy to include interventions for oxygen delivery, tubing changes, and monitoring per facility policy.
F 0684: The facility failed to provide supervision for a resident requiring feeding assistance, resulting in the resident eating unsupervised despite aspiration precautions.
F 0686: The facility failed to follow the plan of care for a resident with pressure ulcers by not ensuring proper air mattress function and turning/repositioning every 2 hours.
F 0689: The facility failed to provide adequate supervision to prevent elopement for residents at risk, resulting in multiple elopement incidents and lack of staff education.
F 0730: The facility failed to ensure required annual performance evaluations were completed for multiple nursing assistants.
F 0761: The facility failed to date multi-dose Tuberculin PPD vials upon opening, risking medication efficacy and test accuracy.
F 0806: The facility failed to provide selective menus for residents, limiting resident choice and resulting in repeated meals and delayed alternative meals.
F 0812: The facility failed to maintain safe food temperatures during transport and failed to maintain dishwasher water temperatures at or above 160°F.
F 0880: The facility failed to label, date, and properly store oxygen tubing per facility policy for multiple residents receiving oxygen therapy.
F 0941: The facility failed to ensure required Communication in-service training was completed and documented for multiple nursing assistants.
F 0947: The facility failed to provide required annual training for nurse aides in dementia care, resident rights, communication, and abuse prevention.
Report Facts
Residents at risk for elopement on unit K1: 32
Residents at risk for elopement on unit K2: 31
Stage II pressure ulcer size left buttock: 1.5
Stage II pressure ulcer size left buttock: 1.7
Stage II pressure ulcer size right buttock: 0.6
Stage II pressure ulcer size right buttock: 0.5
Oxygen tubing change documented dates: 2
Dishwasher temperature: 149
Dishwasher temperature after repair: 170
Food temperature on test tray: 121.5
Food temperature on test tray: 129.9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #9 | Licensed Practical Nurse | Named in physical restraint and abuse allegation involving Resident #20 |
| NA #10 | Nursing Assistant | Witnessed alleged abuse incident involving Resident #20 |
| RN #5 | Registered Nurse | Identified care plan update issues for oxygen therapy residents |
| LPN #4 | Licensed Practical Nurse | Responsible for updating Resident Care Plans for long-term care residents |
| RN #3 | Registered Nurse | Identified feeding supervision failure for Resident #62 |
| ST #1 | Speech Therapist | Provided dysphagia therapy and feeding supervision recommendations for Resident #62 |
| LPN #1 | Licensed Practical Nurse | Responsible nurse for Resident #46, involved in pressure ulcer care deficiency |
| LPN #6 | Unit Manager | Identified care plan and repositioning deficiencies for Resident #46 |
| PA #1 | Physician Assistant | Provided medical assessment and care recommendations for Residents #20 and #46 |
| DNS | Director of Nursing Services | Provided multiple interviews regarding facility policies, investigations, and deficiencies |
| NA #7 | Nursing Assistant | Escorted Resident #14 during elopement incident |
| Security Guard #1 | Security Guard | Located and returned Resident #80 after elopement |
| RN #1 | Registered Nurse | Staff Development Nurse, responsible for training documentation |
Inspection Report
Routine
Deficiencies: 15
Date: Feb 25, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, safety, and facility operations, including review of complaints, care plans, medication administration, elopement risks, and infection control.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity with urinary catheter privacy covers, inadequate supervision and risk assessment for secured units, failure to keep a resident free from physical restraint, incomplete care plans for elopement risk, failure to update care plans for oxygen therapy, lack of supervision during feeding for a resident with aspiration precautions, failure to follow pressure ulcer care plans, inadequate supervision to prevent elopement, missing annual employee performance evaluations, failure to date multi-dose medication vials, lack of selective menus for residents, improper food temperature maintenance, failure to label and date oxygen tubing, and incomplete required staff training documentation.
Deficiencies (15)
Failure to maintain dignity for a resident with a urinary catheter drainage bag by not properly covering the drainage bag with a privacy cover.
Failure to ensure residents who did not meet clinical criteria to reside on a locked unit were provided with a method of opening doors independently.
Failure to keep a resident free from physical restraint, including an incident where a nurse hit a resident's arm during medication administration.
Failure to develop a comprehensive Resident Care Plan for a resident at risk for elopement.
Failure to revise Resident Care Plans for residents on oxygen therapy per facility policy.
Failure to provide supervision for a resident who required supervised feeding, resulting in the resident eating alone without staff supervision.
Failure to follow the plan of care for a resident with pressure ulcers, including failure to turn and reposition every 2 hours and failure to maintain air mattress function.
Failure to provide adequate supervision to prevent elopement for residents at risk, including incidents of residents leaving the facility unattended.
Failure to ensure required annual performance evaluations were completed for multiple nursing assistants.
Failure to date multi-dose Tuberculin PPD vials upon opening in medication storage rooms.
Failure to provide a selective menu for residents to make meal selections, resulting in residents not knowing their meal choices until served.
Failure to maintain food temperatures above 135 degrees Fahrenheit during transport and failure to maintain dishwasher hot water temperatures at or above 160 degrees Fahrenheit.
Failure to label, date, and store oxygen tubing per facility policy for multiple residents receiving oxygen therapy.
Failure to ensure required Communication training/in-service was completed for multiple nursing assistants.
Failure to provide required annual training for nurse aides including Resident Rights, Dementia, Communication, and Behavioral Health.
Report Facts
Residents at risk for elopement: 63
Pressure ulcer size: 1.7
Pressure ulcer size: 0.6
Oxygen tubing change frequency: 7
Dishwasher temperature: 149
Dishwasher temperature after repair: 170
Food temperature: 121.5
Food temperature: 129.9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #9 | Licensed Practical Nurse | Named in physical restraint and abuse incident involving Resident #20 |
| NA #10 | Nursing Assistant | Witnessed physical restraint incident involving Resident #20 |
| LPN #1 | Licensed Practical Nurse | Named in pressure ulcer care and repositioning deficiency for Resident #46 |
| LPN #6 | Unit Manager | Provided information on secured unit policies and pressure ulcer care for Resident #46 |
| RN #4 | Registered Nurse | Responsible for oxygen tubing changes and documentation |
| RN #1 | Staff Development Nurse | Unable to provide documentation for required communication training for nursing assistants |
| DNS | Director of Nursing Services | Provided multiple interviews regarding facility policies, deficiencies, and staff training |
| Security Guard #1 | Security Guard | Involved in elopement incident response for Resident #80 |
| NA #7 | Nursing Assistant | Escorted Resident #14 to medical appointment and involved in elopement incident |
| LPN #8 | Licensed Practical Nurse | Interviewed regarding elopement incident and oxygen tubing labeling |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Dec 9, 2024
Visit Reason
The inspection was conducted due to allegations of staff to resident verbal and physical abuse involving three residents and a nurse aide during the 3-11PM shift on 11/24/24.
Complaint Details
The complaint investigation involved allegations of verbal and physical abuse by Nurse Aide #2 towards Residents #1, #2, and #3 on 11/24/24. The facility failed to report these allegations within two hours as required. The nurse aide was terminated on 11/27/24 following the investigation.
Findings
The facility failed to ensure Resident #1 was not physically and verbally abused, and Residents #2 and #3 were not verbally abused by a nurse aide. The nurse aide (NA #2) was found to have violated facility policies on Abuse and Neglect and Resident Rights, resulting in termination. Additionally, the facility failed to timely report the abuse allegations to the Administrator and/or designee within two hours as required by policy.
Deficiencies (2)
Failure to protect residents from verbal and physical abuse by a nurse aide.
Failure to timely report allegations of abuse to the Administrator and/or designee within two hours.
Report Facts
Incidents: 3
Residents reviewed: 4
Date of incidents: Nov 24, 2024
Date of nurse aide termination: Nov 27, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Aide #2 | Nurse Aide | Named in findings for verbal and physical abuse of residents and violation of facility policies |
| Nurse Aide #1 | Nurse Aide | Reported concerns about Nurse Aide #2's behavior |
| Director of Nursing | Director of Nursing | Interviewed regarding the investigation and abuse reporting failures |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Dec 9, 2024
Visit Reason
The investigation was conducted due to allegations of staff to resident verbal and physical abuse involving three residents and a nurse aide.
Complaint Details
The complaint investigation involved allegations of verbal and physical abuse by Nurse Aide #2 towards Residents #1, #2, and #3 on 11/24/24. The facility failed to report the allegations within two hours as required. The nurse aide was terminated on 11/27/24 following the investigation.
Findings
The facility failed to prevent verbal and physical abuse by a nurse aide towards residents and failed to timely report the abuse allegations to the Administrator and other authorities. The nurse aide was terminated following the investigation.
Deficiencies (2)
F 0600: The facility failed to protect residents from verbal and physical abuse by a nurse aide. Resident #1 was physically and verbally abused, and Residents #2 and #3 were verbally abused by the nurse aide.
F 0609: The facility failed to timely report allegations of abuse to the Administrator and other authorities within two hours as required by policy.
Report Facts
Incidents: 3
Residents sampled: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Aide #2 | Nurse Aide | Named in findings for verbal and physical abuse of residents |
| Nurse Aide #1 | Nurse Aide | Reported concerns about Nurse Aide #2 and witnessed abuse |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding abuse allegations and investigation |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Nov 25, 2024
Visit Reason
The inspection was conducted to investigate a complaint regarding the facility's failure to timely notify the physician or APRN after a resident verbalized self-harm.
Complaint Details
The complaint investigation found that Resident #1 verbalized suicidal ideation on 11/8/2024. The facility did not notify the physician/APRN as required. The ADNS and DON confirmed lack of notification and absence of documented physician evaluation. The complaint was substantiated with minimal harm.
Findings
The facility failed to ensure timely notification of the physician/APRN after Resident #1 verbalized self-harm on 11/8/2024. Interviews and record reviews confirmed that the physician was not notified and safety precautions were inconsistently applied.
Deficiencies (1)
F 0580: The facility failed to notify the physician/APRN timely after Resident #1 verbalized self-harm on 11/8/2024. Safety precautions were maintained but physician notification and one-to-one supervision were not confirmed.
Report Facts
Severity level: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in failure to notify physician after resident's self-harm verbalization |
| ADNS | Acting Director of Nursing Services | Notified by LPN #1 but unaware of incident; did not notify physician |
| DON | Director of Nursing | Confirmed lack of notification and absence of physician evaluation |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Nov 25, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to timely notify a physician or APRN after a resident verbalized self-harm.
Complaint Details
The complaint investigation found that Resident #1 verbalized self-harm on 11/8/2024, but the physician/APRN was not notified. The ADNS was unaware of the incident and stated that had she been notified, she would have informed the physician. The DON confirmed no documentation of physician evaluation and stated Resident #1 would have been sent to hospital if necessary.
Findings
The facility failed to ensure timely notification of the physician/APRN after Resident #1 verbalized self-harm on 11/8/2024. Staff maintained safety precautions but did not notify the physician, and no documentation was found that Resident #1 was evaluated by a physician or psychiatric services.
Deficiencies (1)
Failure to ensure staff notified the physician/APRN timely after a resident's verbalization of self-harm.
Report Facts
Residents Affected: 1
Date of incident: Nov 8, 2024
Date of survey: Nov 25, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Nurse who documented Resident #1's verbalization of self-harm and notified ADNS |
| ADNS | Acting Director of Nursing Services | RN Supervisor for the shift, was not notified of the incident |
| DON | Director of Nursing | Interviewed regarding notification and evaluation procedures |
| APRN #2 | Advanced Practice Registered Nurse | Unable to be interviewed during survey |
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Apr 15, 2024
Visit Reason
The inspection was conducted as a regulatory annual survey to assess compliance with healthcare standards and investigate medication administration and wound care practices.
Findings
The facility failed to ensure proper wound care was performed as ordered, administered the incorrect intravenous solution to a resident, and failed to prevent omission of medication doses due to transcription errors. These deficiencies posed minimal harm or potential for actual harm to residents.
Deficiencies (3)
F 0684: The facility failed to follow a physician's order for daily wound care on Resident #1, resulting in missed treatments from 3/6/24 to 3/8/24 despite documentation indicating otherwise.
F 0694: The facility failed to administer the correct intravenous solution as prescribed for Resident #2, resulting in the wrong IV fluid being given on 12/2/23.
F 0760: The facility failed to ensure a medication for Resident #12's anxiety was not discontinued without a physician's order, causing omission of multiple doses and subsequent hospitalization.
Report Facts
Missed doses of Ativan: 56
IV fluid rate: 100
Wound size: 3.3
Wound size: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #4 | Licensed Practical Nurse | Named in wound care deficiency for failing to perform wound care on Resident #1 from 3/6/24 to 3/8/24. |
| LPN #2 | Licensed Practical Nurse | Named in IV fluid administration deficiency for hanging the wrong IV solution on 12/2/23 for Resident #2. |
| RN #3 | Registered Nurse | Named in medication transcription error for Resident #12's Ativan order. |
Inspection Report
Deficiencies: 3
Date: Apr 15, 2024
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to wound care, medication administration, and medication error prevention at Mary Wade Home, the Incorporated.
Findings
The facility failed to ensure physician orders were followed for wound care, resulting in missed wound treatments for Resident #1. The facility also failed to administer the correct intravenous solution for Resident #2 and failed to prevent omission of several doses of medication for Resident #12 due to transcription errors. These deficiencies were associated with minimal harm or potential for actual harm to residents.
Deficiencies (3)
Failed to ensure physician's order was followed and wound care was conducted daily for Resident #1 with a skin tear.
Failed to administer the correct intravenous solution as prescribed for Resident #2.
Failed to ensure medication for Resident #12's anxiety was not discontinued without a physician's order, resulting in omission of several doses.
Report Facts
Deficiencies cited: 3
Missed medication doses: 56
IV fluid rate: 100
Wound size: 3.3
Wound size: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #4 | Licensed Practical Nurse | Assigned to Resident #1 on 3/6/24 through 3/8/24 and failed to perform wound care despite signing off treatments. |
| LPN #6 | Licensed Practical Nurse | Wound care nurse who identified missed wound care treatments for Resident #1. |
| Director of Nursing | Director of Nursing | Identified failures in wound care and medication administration and provided policy context. |
| LPN #2 | Licensed Practical Nurse | Admitted to hanging the wrong IV solution for Resident #2 on 12/2/23. |
| RN #3 | Registered Nurse | Took verbal order from psychiatric physician for Resident #12's Ativan and transcribed order with a stop date. |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Nov 1, 2023
Visit Reason
The inspection was conducted following complaints related to resident falls and failure to follow care plans, focusing on resident safety, fall risk assessments, and adherence to transfer protocols.
Complaint Details
The investigation was complaint-driven, focusing on falls involving Residents #1, #2, and #3. Resident #1 fell from a wheelchair due to improper transfer by staff. Resident #2 fell from bed resulting in a head laceration. Fall risk assessments were not completed as required for Residents #1 and #3. Staff disciplinary actions were taken related to these incidents.
Findings
The facility failed to ensure proper adherence to resident care plans, resulting in falls and injuries. Fall risk assessments were not completed as required, and staff did not consistently follow safe transfer and handling policies, leading to resident injuries including a fall from a wheelchair and a fall from bed causing a laceration.
Deficiencies (3)
F 0656: The facility failed to develop and implement a complete care plan ensuring Resident #1 was transported per the care plan, resulting in a fall when transferred by insufficient staff.
F 0684: The facility failed to complete fall risk assessments for Residents #1 and #3 in accordance with facility policies, missing assessments between specified dates.
F 0689: The facility failed to protect Resident #2's safety during care, resulting in a fall from bed and a laceration requiring staples due to inadequate supervision and failure to maintain bed rails and bed position.
Report Facts
Date of physician's order: Jun 13, 2023
Date of physician's order: May 10, 2023
Date of physician's order: Jun 10, 2021
Date of fall incident: Oct 9, 2023
Date of fall incident: Sep 18, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NA #1 | Named in disciplinary action for failing to follow Resident #1's care plan leading to fall | |
| LPN #1 | Assisted NA #1 in transferring Resident #1 to shower chair | |
| NA #2 | Involved in care of Resident #2 during fall incident from bed | |
| DNS | Director of Nursing Services | Interviewed regarding fall risk assessment responsibilities and expectations |
| MDS nurse | Interviewed about fall risk assessment duties | |
| Administrator | Interviewed regarding fall incident investigation | |
| APRN | Advanced Practice Registered Nurse | Assessed Resident #1 and Resident #2 after falls |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Nov 1, 2023
Visit Reason
The inspection was conducted following complaints and incidents involving resident falls and failure to follow care plans, specifically related to safe transfers and fall risk assessments.
Complaint Details
The complaint investigation was substantiated by findings that staff did not follow the resident's care plan for transfers, leading to a fall and injury. Additionally, fall risk assessments were not completed as required, and inadequate supervision contributed to a resident falling from bed and sustaining a laceration.
Findings
The facility failed to ensure proper adherence to resident care plans for transfers, resulting in a resident fall with injury. Additionally, the facility did not complete required fall risk assessments in accordance with policy and failed to provide adequate supervision to prevent accidents, leading to another resident's fall from bed causing a laceration requiring staples.
Deficiencies (3)
Failed to develop and implement a complete care plan that meets all the resident's needs, including assistance of two staff for transfers, resulting in a resident fall.
Failed to provide appropriate treatment and care according to orders and resident preferences, including failure to complete fall risk assessments as required.
Failed to ensure the nursing home area was free from accident hazards and provide adequate supervision, resulting in a resident fall from bed with a head laceration requiring staples.
Report Facts
Date of physician order: Jun 13, 2023
Date of physician order: May 10, 2021
Date of physician order: Jun 10, 2021
Date of fall incident: Oct 9, 2023
Date of fall incident: Sep 18, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NA #1 | Nursing Assistant | Named in disciplinary action for not following resident's care plan leading to fall |
| LPN #1 | Licensed Practical Nurse | Assisted in transferring Resident #1 to shower chair |
| NA #2 | Nursing Assistant | Named in Resident #2 fall incident for leaving bed rails down and bed raised |
| DNS | Director of Nursing Services | Interviewed regarding fall risk assessment responsibilities and expectations |
| ADNS | Assistant Director of Nursing Services | Interviewed regarding fall incident investigation |
| Administrator | Interviewed regarding fall incident investigation | |
| APRN | Advanced Practice Registered Nurse | Assessed Resident #1 and Resident #2 after falls |
| MDS nurse | Minimum Data Set Nurse | Interviewed regarding fall risk assessment completion duties |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Feb 15, 2023
Visit Reason
The inspection was conducted to investigate complaints regarding the facility's failure to develop and implement appropriate care plans, monitor skin integrity under geriatric sleeves, and assess range of motion and splint use for a resident at risk for skin breakdown and contractures.
Complaint Details
The complaint investigation focused on Resident #1 who was at risk for skin breakdown and had contractures. The investigation substantiated failures in care planning, skin monitoring under geriatric sleeves, and rehabilitation evaluation after hospital readmission.
Findings
The facility failed to ensure a complete care plan for the use of geriatric sleeves, did not adequately monitor skin under the sleeves leading to a pressure wound, and failed to assess and document the resident's range of motion and need for splints. Interviews revealed inconsistent care practices and lack of policies for geriatric sleeve use and rehabilitation screening.
Deficiencies (3)
F 0656: The facility failed to develop and implement a complete care plan for the use of geriatric sleeves for a resident at risk for skin breakdown.
F 0684: The facility failed to monitor skin under geriatric sleeves to ensure skin integrity, resulting in a pressure wound with exposed vessels and nerves.
F 0688: The facility failed to assess and measure a resident's range of motion to determine the necessity of splints and did not document physical therapy evaluations after hospital readmission.
Report Facts
Pressure wound size: 3
Superficial wound size: 2
Braden Risk Assessment score: 15
Splint screen date: Nov 17, 2022
Physician order date: Jan 8, 2023
Nursing progress note date: Jan 15, 2023
Plastic surgery consult date: Jan 16, 2023
Rehabilitation screening request date: Jan 16, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Aide #1 | Nurse Aide | Provided care to Resident #1 and described geriatric sleeve use and skin checks |
| Licensed Practical Nurse #1 | Charge Nurse | Conducted weekly skin checks and described responsibilities for geriatric sleeve care |
| Director of Nursing | Director of Nursing (DON) | Provided expectations for geriatric sleeve use, skin checks, and rehabilitation evaluations |
| Wound Specialist | Facility Wound Specialist | Treated Resident #1 and identified likely cause of pressure wound |
| Occupational Therapist #1 | Occupational Therapist | Completed splint screen and discussed evaluation challenges |
| Advanced Practice Registered Nurse #1 | APRN | Reviewed discharge paperwork and expected rehabilitation re-evaluation |
| Director of Rehabilitation | Director of Rehabilitation | Discussed rehabilitation screening and evaluation policies and gaps |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Feb 15, 2023
Visit Reason
The inspection was conducted based on a complaint investigation concerning the care and treatment of Resident #1, specifically regarding the failure to implement and monitor the use of geriatric sleeves to prevent skin breakdown and the failure to assess and measure the resident's range of motion and splint use.
Complaint Details
The complaint investigation focused on Resident #1 who was at risk for skin breakdown and had contractures. The investigation found failures in care planning, monitoring of skin integrity under geriatric sleeves, and rehabilitation evaluation for splint use. The wound specialist and nursing staff interviews confirmed inadequate monitoring and care. The resident developed a pressure wound requiring hospitalization.
Findings
The facility failed to develop and implement a complete care plan for the use of geriatric sleeves, failed to monitor skin integrity under the sleeves leading to a pressure wound, and failed to assess and document the resident's range of motion and need for splints. Interviews and clinical record reviews revealed inadequate care planning, monitoring, and rehabilitation evaluation for Resident #1.
Deficiencies (3)
Failed to ensure a care plan was in place for the use of geriatric sleeves for a resident at risk for skin breakdown.
Failed to monitor skin under the geriatric sleeve to ensure skin was intact and no open areas developed.
Failed to assess and measure a resident's current extent of movement of joints to determine if splints were necessary to prevent decline in movement.
Report Facts
Pressure wound size: 3
Pressure wound size: 2
Splint screen date: Nov 17, 2022
Physician order date: Jan 8, 2023
Nursing progress note date: Jan 15, 2023
Plastic surgery consult date: Jan 16, 2023
Readmission note date: Jan 31, 2023
Rehabilitation screening request date: Jan 16, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Aide #1 | Nurse Aide | Interviewed regarding care and removal of geriatric sleeves for Resident #1 |
| Licensed Practical Nurse #1 | Charge Nurse | Interviewed about responsibility for changing geriatric sleeves and conducting skin checks |
| Director of Nursing | Director of Nursing (DON) | Interviewed about expectations for geriatric sleeve care and monitoring, and rehabilitation evaluations |
| Wound Specialist | Facility Wound Specialist | Interviewed about cause of pressure wound and care concerns |
| Occupational Therapist #1 | Occupational Therapist | Interviewed about splint screen and evaluation of Resident #1 |
| Advanced Practice Registered Nurse #1 | APRN | Interviewed about discharge paperwork review and expectations for rehabilitation re-evaluation |
| Director of Rehabilitation | Director of Rehabilitation | Interviewed about screening evaluations and lack of documented re-evaluation |
Inspection Report
Routine
Deficiencies: 18
Date: Jan 4, 2023
Visit Reason
Routine state inspection of Mary Wade Home nursing facility to assess compliance with regulatory requirements including resident care, safety, nutrition, infection control, and facility maintenance.
Findings
The inspection identified multiple deficiencies including failure to update physician orders for code status, failure to address significant weight discrepancies timely, failure to maintain resident privacy, delayed reporting of abuse allegations, incomplete resident assessments, inaccurate MDS coding, medication administration errors, failure to implement fall interventions timely, improper storage and handling of medications and equipment, and inadequate infection control practices.
Deficiencies (18)
F 0578: The facility failed to obtain a physician's order reflecting a change from Do Not Resuscitate to CPR for Resident #61, causing potential confusion in emergency care.
F 0580: The facility failed to notify the APRN and dietician timely regarding significant weight loss for Resident #9 and weight gain for Resident #60, delaying nutritional interventions.
F 0583: The facility failed to protect Resident #29's privacy by posting personal dental care instructions on the wall in a semi-private room visible to the public.
F 0609: The facility failed to timely report an allegation of abuse involving Resident #61 to the state agency, delaying investigation.
F 0636: The facility failed to complete Resident #10's annual MDS assessment within 14 days and failed to accurately code Resident #60's Level 2 PASARR status on admission MDS.
F 0637: The facility failed to complete a significant change MDS assessment within 14 days of Resident #38 electing hospice services.
F 0640: The facility failed to transmit Resident #26's quarterly MDS assessment to the state within 14 days of completion.
F 0641: The facility failed to accurately code Resident #63's bladder continence status on annual and quarterly MDS assessments, requiring correction after surveyor inquiry.
F 0657: The facility failed to ensure Resident #338's Foley catheter collection bag was off the floor and failed to document Resident #27's participation or refusal in care planning meetings.
F 0658: The facility failed to document a psychiatric assessment and notification to responsible party after an incident involving Resident #36 being kissed by another resident.
F 0684: The facility failed to follow physician's orders consistently for Resident #336, resulting in 3 missed doses of furosemide despite weight criteria being met.
F 0692: The facility failed to address significant weight discrepancies timely for Residents #9 and #60, delaying dietitian evaluation and reweighs as required by policy.
F 0694: The facility failed to ensure scheduled PICC line dressing changes and catheter measurements were completed per policy for Resident #387.
F 0761: The facility failed to secure medications properly when unattended, leaving medication cart unlocked with medications exposed in hallways.
F 0770: The facility failed to provide timely laboratory services as ordered for Resident #387, delaying required weekly lab work.
F 0803: The facility failed to follow the menu and provide nutritional supplements as ordered for Resident #59, substituting foods and omitting supplements.
F 0880: The facility failed to maintain Resident #338's Foley catheter bag off the floor, failed to follow glucometer disinfection procedures, and improperly stored bed pans and bath basins in resident bathrooms.
F 0908: The facility failed to ensure Resident #27's wheelchair was maintained in good repair, with a missing hand brake and no effective preventative maintenance program in place.
Report Facts
Weight loss: 23.6
Weight loss percentage: 13.3
Missed medication doses: 3
Weight gain percentage: 27
Weight gain percentage: 10.8
Weight loss percentage: 6
Weight loss percentage: 21
Weight loss percentage: 5
Weight loss: 6.2
Weight loss percentage: 8.2
Weight loss percentage: 5
Weight loss percentage: 13
Weight gain percentage: 18
Weight gain percentage: 10.8
Weight gain percentage: 27
Weight gain percentage: 18
Weight gain percentage: 10.8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #4 | Licensed Practical Nurse | Identified missing physician order for CPR status change and medication administration issues |
| LPN #5 | Nursing Supervisor | Discussed weight monitoring and reweigh procedures |
| LPN #8 | Licensed Practical Nurse | Discussed medication incident and weight documentation |
| DNS | Director of Nursing Service | Provided multiple interviews on weight monitoring, abuse reporting, and nursing documentation |
| APRN #1 | Psychiatric Advanced Practice Registered Nurse | Completed psychiatric assessment not documented timely |
| Dietician | Discussed weight loss and nutritional interventions for Resident #9 and #60 | |
| NA #2 | Nursing Assistant | Reported abuse allegation and discussed bath basin and bed pan storage |
| RN #1 | Infection Preventionist | Discussed PICC line dressing and catheter measurement |
| LPN #1 | Licensed Practical Nurse | Observed Foley catheter bag on floor and moved it |
| LPN #3 | Infection Preventionist | Provided glucometer cleaning policy and training |
| LPN #7 | Licensed Practical Nurse | Left medication cart unattended during emergency |
| Director of Food Services | Discussed menu substitutions and meal ticket discrepancies | |
| Maintenance Associate #1 | Discussed wheelchair maintenance and repair | |
| Maintenance Associate #2 | Repaired wheelchair brake | |
| Social Worker #1 | Discussed incorrect PASARR coding | |
| Social Worker #2 | Discussed Resident #27 care planning meeting attendance and documentation |
Inspection Report
Routine
Deficiencies: 18
Date: Jan 4, 2023
Visit Reason
The inspection was conducted as a routine regulatory survey of Mary Wade Home, the Incorporated, to assess compliance with healthcare facility regulations including resident care, safety, and infection control.
Findings
The survey identified multiple deficiencies including failure to update resident code status orders, failure to address significant weight discrepancies timely, failure to maintain resident privacy, delayed reporting of abuse allegations, incomplete resident assessments, inaccurate MDS coding, failure to document resident participation in care planning, medication administration errors, unsafe medication storage, incomplete IV therapy monitoring, failure to follow infection control practices, and inadequate maintenance of medical equipment.
Deficiencies (18)
Failed to obtain a physician's order reflecting a change from Do Not Resuscitate to CPR for Resident #61.
Failed to notify APRN and dietician of significant weight discrepancies for Residents #9 and #60.
Failed to provide privacy by posting Resident #29's personal care instructions on the wall in public view.
Failed to timely report an allegation of abuse involving Resident #61 to the state agency.
Failed to complete Resident #10's annual MDS assessment within 14 days and failed to accurately code Resident #60's PASARR Level 2 status.
Failed to complete a significant change MDS assessment within 14 days of hospice election for Resident #38.
Failed to transmit Resident #26's quarterly MDS assessment within 14 days of completion.
Failed to ensure accurate bladder status coding on MDS assessments for Resident #63.
Failed to ensure Foley catheter tubing and bag were maintained off the floor for Resident #338.
Failed to document Resident #27's participation, refusal, or input into care planning meetings.
Failed to document psychiatric assessment and notification to responsible party after an incident involving Resident #36.
Failed to follow physician's order to administer furosemide as needed for Resident #336 resulting in missed doses.
Failed to ensure timely PICC line dressing changes and catheter measurements for Resident #387.
Failed to secure medication cart and left medications unattended in hallway.
Failed to ensure laboratory blood work was completed timely for Resident #387.
Failed to follow menu and provide nutritional supplements as ordered for Resident #59.
Failed to properly clean and disinfect glucometer and failed to store bath basins and bed pans in a sanitary manner.
Failed to maintain wheelchair in good repair; Resident #27's wheelchair brake was missing and maintenance checks were not performed.
Report Facts
Weight loss: 23.6
Weight loss: 6.2
Weight gain: 27
Missed medication doses: 3
Fall intervention delay: 58
Weight increase: 10.8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #4 | Licensed Practical Nurse | Identified failure to update code status orders for Resident #61 |
| Director of Nursing Service (DNS) | Director of Nursing | Provided multiple interviews regarding weight discrepancy and reporting delays |
| Dietician | Dietician | Interviewed regarding weight monitoring and reweigh procedures |
| LPN #5 | Nursing Supervisor | Interviewed regarding weight reconciliation and communication |
| NA #2 | Nurse Aide | Reported abuse allegation for Resident #61 |
| APRN #1 | Psychiatric Advanced Practice Registered Nurse | Completed psychiatric assessment but failed to document in chart |
| LPN #8 | Licensed Practical Nurse | Recalled incident of Resident #36 being kissed and documentation issues |
| LPN #7 | Licensed Practical Nurse | Documented Resident #9's weight and discussed reweigh procedures |
| RN #1 | Infection Preventionist | Interviewed regarding PICC line dressing and catheter care |
| LPN #1 | Licensed Practical Nurse | Observed leaving medication cart unattended and confirmed Foley bag on floor |
| Maintenance Associate #1 | Maintenance Staff | Interviewed regarding wheelchair maintenance and repair |
| Director of Food Services | Food Service Director | Interviewed regarding menu substitutions and meal preparation |
Inspection Report
Monitoring
Census: 23
Capacity: 45
Deficiencies: 0
Date: May 11, 2020
Visit Reason
The visit was an unannounced COVID-19 Infection Control monitoring visit conducted by the Department of Public Health on May 11, 2020.
Findings
No violations of the Regulations of Connecticut State Agencies or General Statutes of Connecticut were identified during the inspection.
Report Facts
Licensed Bed Capacity: 45
Census: 23
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stanley DeCosta | Person-in-Charge | Named as personnel contacted during inspection |
| Joy Rembet | Manager | Named as personnel contacted during inspection |
| Karen Gworek | Supervising Nurse Consultant | Author of the report letter |
Inspection Report
Deficiencies: 2
Date: Feb 6, 2020
Visit Reason
The inspection was conducted to assess compliance with pre-admission screening and resident review (PASRR) requirements and to evaluate the facility's immunization policies and procedures for flu and pneumonia vaccinations.
Findings
The facility failed to provide an occupational therapy evaluation and failed to obtain previous psychiatric records for one resident as recommended by PASRR. Additionally, the facility failed to ensure that pneumococcal vaccines were administered according to standards of practice and facility policy for three residents.
Deficiencies (2)
Failed to provide an occupational therapy evaluation and failed to obtain previous psychiatric records per PASRR recommendations for Resident #26.
Failed to ensure pneumococcal vaccines were administered according to standards of practice and facility policy for Residents #20, #21, and #86.
Report Facts
Residents reviewed for PASRR: 3
Residents reviewed for immunizations: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #2 | Registered Nurse | Interviewed regarding mailing out consent forms for PPSV23 and vaccination process. |
| Director of Nurses | DNS | Interviewed regarding facility policy and expectations for occupational therapy evaluations and pneumococcal vaccinations. |
| Rehabilitation Director | Interviewed regarding occupational therapy evaluation for Resident #26. |
Inspection Report
Deficiencies: 2
Date: Feb 6, 2020
Visit Reason
The inspection was conducted to assess compliance with pre-admission screening and resident review (PASRR) requirements and to evaluate the facility's immunization policies and procedures for flu and pneumonia vaccinations.
Findings
The facility failed to provide an occupational therapy evaluation and obtain previous psychiatric records for one resident as required by PASRR recommendations. Additionally, the facility failed to ensure that pneumococcal vaccines were administered according to standards of practice and facility policy for three residents.
Deficiencies (2)
F 0644: The facility failed to provide an occupational therapy evaluation and obtain previous psychiatric records for Resident #26 as recommended by the PASRR Level II assessment.
F 0883: The facility failed to ensure pneumococcal vaccines were administered according to standards of practice and facility policy for Residents #20, #21, and #86.
Report Facts
Residents reviewed for immunizations: 5
Residents with pneumococcal vaccine deficiencies: 3
Residents reviewed for PASRR: 3
Residents with PASRR deficiency: 1
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