Inspection Report Summary
The most recent inspection on June 26, 2024, identified deficiencies related to violations of Connecticut statutes and regulations during a complaint investigation. Earlier inspections also found violations, including substantiated complaints in October 2023 and deficiencies involving client safety and elopement policy compliance in April 2023. The main themes across these findings involved regulatory compliance and client safety procedures, particularly around elopement risk management. Complaint investigations were substantiated in some cases, while others did not specify substantiation status. The inspection history shows ongoing challenges with compliance, as deficiencies have appeared consistently over time without a clear pattern of improvement.
Deficiencies (last 3 years)
Deficiencies (over 3 years)
0.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
95% better than Connecticut average
Connecticut average: 5.6 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
18 residents
Based on a April 2023 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jun 26, 2024
Visit Reason
The inspection was conducted as a complaint investigation related to Complaint #39541.
Complaint Details
Complaint investigation #39541 was the reason for the visit; violations were identified.
Findings
Violations of the General Statutes of Connecticut and/or regulations of Connecticut State Agencies were identified at the time of this inspection. Verification of Alzheimer's special care units and part-time Infection Prevention and Control Specialist requirements were also confirmed.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Michael J. Smith | Nurse Consultant | Signature of FLIS Staff and report submitter |
| Valerie RomanoDumais | Executive | Personnel contacted during inspection |
| Dana Arcouette | SALSA | Personnel contacted during inspection |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jun 26, 2024
Visit Reason
The inspection was conducted as a complaint investigation related to Complaint #39541 and included verification of Alzheimer's special care units and infection prevention and control requirements.
Complaint Details
Complaint investigation #39541 was the reason for the visit. Specific substantiation status is not stated.
Findings
Violations of the General Statutes of Connecticut and/or regulations of Connecticut State Agencies were identified at the time of this inspection, as indicated by the attached violation letter dated 7/18/24.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Michael J. Smith | Nurse Consultant | Signature of FLIS staff conducting the inspection and submitting the report. |
| Valerie Romano Dumais | Executive | Personnel contacted during the inspection. |
| Dana Arcouette | SALSA | Personnel contacted during the inspection. |
Inspection Report
Monitoring
Deficiencies: 0
Date: Oct 17, 2023
Visit Reason
The inspection was conducted as a strike monitoring visit related to Complaint Investigation #34943.
Complaint Details
Visit was related to Complaint Investigation #34943; no substantiation status provided.
Findings
The report does not provide detailed findings or deficiencies; it is a licensing inspection supplement for strike monitoring purposes.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Megan Edson-Sawyer | Survey Team Leader / Nurse Consultant | Named as Survey Team Leader and Report Submitter. |
| Elizabeth Heiney | Supervisor | Named as Supervisor. |
| Annie Stone | Personnel contacted during inspection. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Oct 17, 2023
Visit Reason
The inspection visit was conducted as a complaint investigation identified by Complaint Investigation #34943.
Complaint Details
Complaint Investigation #34943 was substantiated with violations found during the inspection.
Findings
Violations of the General Statutes of Connecticut and/or regulations of Connecticut State Agencies were identified at the time of this inspection, as noted in the attached violation letter dated 11/2/23.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Annie Stone | Personnel contacted during the inspection. | |
| Megan Edson-Sawyer | Survey Team Leader | Named as Survey Team Leader for the inspection. |
| Elizabeth Heiney | Supervisor | Named as Supervisor for the inspection. |
Inspection Report
Monitoring
Census: 18
Deficiencies: 0
Date: Apr 5, 2023
Visit Reason
Monitoring visit after the initial licensure inspection conducted on 12/28/2022.
Findings
Facility tour conducted, interview with Executive Director, review of agency manuals, governing authority minutes, weekly/monthly reports, personnel files, clinical record reviews, and assisted living agency client charts. Violations of Connecticut statutes and regulations were identified at the time of inspection.
Report Facts
Memory Care/Traditional Capacity: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Peg Sullivan | Executive Director | Interviewed during the monitoring visit |
| Megan Edson-Sawyer | Nurse Consultant | Signature of FLIS Staff and report submitter |
Inspection Report
Monitoring
Deficiencies: 1
Date: Apr 5, 2023
Visit Reason
An unannounced visit was made to All American Assisted Living At Enfield on April 5, 2023, for the purpose of conducting a Monitoring Re-Visit.
Findings
The Assisted Living Services Agency (ALSA) failed to provide a safe environment and failed to follow the agency's Elopement policy and procedure after a client eloped from the secured unit. Deficiencies included failure to identify updated elopement risk, failure to update the client's service plan, and failure to ensure staff training on the elopement policy.
Deficiencies (1)
Failure to provide a safe environment and follow the agency's Elopement policy and procedure for a client who eloped from the secured unit.
Report Facts
Date of visit: Apr 5, 2023
Elopement incident date: Mar 10, 2023
Client admission date: Jan 21, 2023
Client nursing assessment date: Feb 27, 2023
Alarm release time: 15
Panic bar lock release extension: 30
Deadline for corrective measures: May 31, 2023
Deadline for elopement risk assessments: Jun 15, 2023
Deadline for panic bar lock release extension: May 15, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Elizabeth Heiney | Supervising Nurse Consultant | Author of the initial violation letter and contact for plan of correction |
| Peg Sullivan | Executive Director | Named in relation to the elopement incident and plan of correction submission |
| Yvette Hassett | Resident Care Director | Responsible staff member for ensuring compliance with plan of correction |
| Megan Edson-Swayer | RN | Conducted the unannounced Monitoring Re-Visit |
Inspection Report
Original Licensing
Capacity: 112
Deficiencies: 0
Date: Dec 28, 2022
Visit Reason
Initial licensing inspection to evaluate the facility for licensure.
Findings
No violations of the General Statutes of Connecticut or regulations of Connecticut State Agencies were identified at the time of this initial inspection. Approval for issuance of license was granted.
Report Facts
Licensed Bed/Bassinet Capacity: 112
Census: 0
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Peg Sullivan | Executive Director | Personnel contacted during inspection. |
| Jaimie Girard | Regional VP of Operations | Personnel contacted during inspection. |
| Yvette Hassett | SALSA | Personnel contacted during inspection. |
| Elizabeth T Heiney | SNC | Report submitted by. |
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