Avery Nursing Home: Courtyard Hazards Reach Main Road - CT
When inspectors visited the Noble Building on October 6, 2025, they walked the same ground that residents walk during family visits and recreational activities. What they found, step by step, was a path from a memory care unit to a four-lane road, with almost nothing standing in the way.
It started at the exit door from the unit, which alarmed loudly when opened and required a key to silence it. That detail might sound reassuring. It wasn't. The door led into a fenced courtyard, and the courtyard had problems of its own before anyone got to the gate.
The paved surface was uneven, with a large raised bump near the door. To the left sat a low stone wall, roughly two feet high, running about half the length of the courtyard. The top layer of stones was not cemented in place. The edges were sharp. Beyond the wall, the ground sloped upward through a bed of large, loose, round landscaping rocks. The rocks moved when stepped on. The Assistant Director of Nursing, walking the area with inspectors, cautioned them to be careful on the stones. At the top left corner, near the building, the slope ended in a drop-off roughly four feet straight down. Loose rocks and stones had also scattered onto the walkway itself, creating additional tripping hazards at ground level.
Then there was the gate.
At the far end of the courtyard, a double gate closed with a simple latch that lifted upward. No lock. Inspectors opened it with one finger. On the other side, a paved pathway curved slightly downhill through a wooded area. To the left, a section of fence was broken. Cut brush and tree branches lined the path. The path led to a steep embankment. At the bottom of the embankment was a four-lane road. The pathway also curved toward the facility's parking lot and the two-lane road leading to the building's entrance.
There were no signs anywhere along this route. No notices. Nothing that would have stopped a resident, a visitor, or a staff member from walking out of the courtyard, through the gate, down the path, and into traffic.
The ADNS told inspectors that residents are not permitted in the courtyard without supervision. She also said any resident could open the unit door from inside, but that a resident would not be able to open the gate latch. Inspectors had just opened it with one finger.
When inspectors sat down with the Director of Nursing and the facility Administrator on September 30, 2025, neither could explain why the top stones on the wall had never been cemented down, why loose rocks had been allowed to accumulate on the walking surface, or why the gate had no lock. The facility's own resident rights policy, which inspectors reviewed that day, stated that residents have the right to a safe environment and that the physical environment must not pose a safety risk.
CMS rated the violation under F0689, the tag covering free from accident hazards, at a level of actual harm affecting a few residents.
The courtyard is described in the inspection report as a space where residents go during recreational programming and family visits when the weather allows. The same space had an uneven surface, a wall with sharp unsecured stones, a four-foot drop in the corner, loose rocks across the walkway, and an unlocked gate opening onto a path through broken fencing to a road. The facility knew residents used it. The ADNS knew the door from the unit could be opened by any resident. Nobody had secured the gate.
The inspection was triggered by a complaint. The report does not describe what happened to prompt it.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Avery Nursing Home/noble Building from 2025-10-06 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 24, 2026 · Our methodology
AVERY NURSING HOME/NOBLE BUILDING in HARTFORD, CT was cited for violations during a health inspection on October 6, 2025.
What they found, step by step, was a path from a memory care unit to a four-lane road, with almost nothing standing in the way.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.