Deficiencies (last 4 years)
Deficiencies (over 4 years)
13 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
132% worse than Connecticut average
Connecticut average: 5.6 deficiencies/yearDeficiencies per year
24
18
12
6
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: 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
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
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
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: 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
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 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 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
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. |
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