Inspection Report Summary
The most recent inspection on May 9, 2024 identified deficiencies related to violations of Connecticut statutes and regulations during complaint investigations. Earlier inspections showed a pattern of issues primarily involving clinical documentation, medication management, and investigation of client incidents such as falls and changes in condition. Complaint investigations often found violations, though some complaints were unsubstantiated, and enforcement actions such as violation letters were issued but no fines or license suspensions were listed in the available reports. Prior citations included failures in assessing and documenting client conditions, incomplete investigations after incidents, and medication administration errors. The inspection history shows ongoing challenges with regulatory compliance, with no clear trend of improvement or worsening over time.
Deficiencies (last 6 years)
Deficiencies (over 6 years)
2.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
50% better than Connecticut average
Connecticut average: 5.6 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
136 residents
Based on a January 2024 inspection.
Census over time
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: May 9, 2024
Visit Reason
The inspection was conducted as a complaint investigation related to Complaint CT #38330 (Client #2) and to verify violations of the General Statutes of Connecticut and/or regulations of Connecticut State Agencies.
Complaint Details
Complaint investigation CT #38330 (Client #2) was the reason for the visit. Violations were identified 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. Verification of Alzheimer's special care units and full-time Infection Prevention and Control Specialist requirements were also confirmed.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Karen Donato | Nurse Consultant | Signature of FLIS Staff and report submitted by. |
| Kim Kelly-Rubin | ED | Personnel contacted during inspection. |
| Evelyn DeJesus | SALSA | Personnel contacted during inspection. |
Inspection Report
Complaint Investigation
Capacity: 136
Deficiencies: 0
Date: May 9, 2024
Visit Reason
The inspection was conducted as a complaint investigation related to Complaint Investigation CT #38618 (Client #1).
Complaint Details
Complaint Investigation CT #38618 (Client #1) was the basis 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 infection prevention and control requirements were also conducted.
Report Facts
Total licensed capacity: 136
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Karen Donato | Nurse Consultant | Signature of FLIS Staff and report submitter |
| Kim Kelly-Rubin | ED | Personnel contacted during inspection |
| Evelyn DeJesus | SALSA | Personnel contacted during inspection |
Inspection Report
Complaint Investigation
Census: 136
Deficiencies: 0
Date: Jan 23, 2024
Visit Reason
The inspection visit was conducted as a complaint investigation related to complaint CT# 37083.
Complaint Details
Complaint investigation CT# 37083 was conducted and found no violations; the complaint was not substantiated.
Findings
No violations of the General Statutes of Connecticut and/or regulations of Connecticut State Agencies were identified at the time of this inspection.
Report Facts
Census: 136
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Michael J. Smith | Nurse Consultant | Signature of FLIS Staff who submitted the report |
| Kim Kelly-Rubin | Executive | Personnel contacted during inspection |
Inspection Report
Complaint Investigation
Census: 125
Capacity: 133
Deficiencies: 0
Date: Apr 20, 2022
Visit Reason
The inspection visit was conducted as a complaint investigation related to complaint number 32008.
Complaint Details
Complaint investigation number 32008 was the basis for this visit.
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 6/11/22.
Report Facts
Licensed Bed Capacity: 133
Census: 125
Inspection Report
Complaint Investigation
Census: 125
Capacity: 133
Deficiencies: 0
Date: Apr 20, 2022
Visit Reason
The inspection visit was conducted as a complaint investigation related to complaint number 32008.
Complaint Details
Complaint investigation number 32008 was conducted; violations were found and documented in an attached violation letter.
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 an attached violation letter dated 6/11/22.
Report Facts
Licensed Bed Capacity: 133
Census: 125
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kim Kelly Rubin | ED | Personnel contacted during inspection |
| Nathaliie Murray | SALSA | Personnel contacted during inspection |
| Elizabeth Heiny | Survey Team Leader | Supervisor of the inspection team |
Inspection Report
Renewal
Census: 127
Capacity: 136
Deficiencies: 0
Date: Oct 7, 2021
Visit Reason
The inspection was conducted as a renewal licensing inspection for the facility.
Findings
No violations of the General Statutes of Connecticut and/or regulations of Connecticut State Agencies were identified at the time of this inspection.
Report Facts
Licensed Bed Capacity: 136
Census: 127
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kim Kelly | ED | Personnel contacted during the inspection |
| Robert Enkri | RN | Personnel contacted during the inspection |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: May 17, 2021
Visit Reason
An unannounced visit was made to Bal East Haven on May 17, 2021 by a representative of the Facility Licensing and Investigations Section of the Department of Public Health for the purpose of conducting an investigation related to Complaint CT #30062.
Complaint Details
Complaint CT #30062 triggered the investigation. The report does not explicitly state substantiation status.
Findings
The investigation identified a violation where the Supervisor of Assisted Living Services Agency (SALSA) failed to assess and document Client #1's change in condition pre and post hospitalizations for the period of 4/12/21 through 4/23/21 and failed to review and update Client #1's Service Program accordingly. Multiple clinical record reviews and staff interviews confirmed these failures, including lack of RN assessments prior to and after emergency department transfers.
Deficiencies (1)
Supervisor of Assisted Living Services Agency (SALSA) failed to assess and document Client #1's change in condition pre and post hospitalizations for the period of 4/12/21 through 4/23/21 and failed to review and update Client #1's Service Program with changes in condition and at least every 120 days.
Report Facts
Date of visit: May 17, 2021
Plan of correction submission deadline: Jun 24, 2021
Date measures effective: Jun 28, 2021
Assessment frequency: 120
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Karen Donato | Interim Supervising Nurse Consultant | Signed letter regarding the complaint investigation |
| Robin Tentoni | Supervisor of Assisted Living Services Agency (SALSA) | Named in the deficiency for failure to assess and document client condition changes |
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Apr 27, 2021
Visit Reason
An unannounced visit was made to Bal East Haven on April 27, 2021 by a representative of the Facility Licensing and Investigations Section of the Department of Public Health for the purpose of conducting an investigation with additional information received through April 28, 2021.
Findings
Violations were identified related to failure to ensure clients were free from neglect and failure to conduct complete investigations after unwitnessed falls, including inadequate continence care and failure to identify and investigate internal incident reports with witness statements and timelines.
Deficiencies (2)
ALSA failed to ensure the clients were free from neglect and failed to conduct a complete investigation after an unwitnessed fall, including failure to identify investigations after Client #1 was found wearing urine saturated incontinence briefs while laying on soiled bed linens.
ALSA failed to identify that an internal incident report was completed and/or a complete investigation was conducted to include witness statements and timelines related to Client #2's fall and subsequent injury.
Report Facts
Date of visit: Apr 27, 2021
Date of visit: Apr 28, 2021
Date measures effective: May 27, 2021
Client #1 admission date: Jan 20, 2018
Client #2 admission date: May 15, 2019
Incident report date: Feb 19, 2021
Incident treatment period: 8
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jul 5, 2018
Visit Reason
An unannounced visit was made to BAL East Haven on July 5, 2018 by a representative of the Facility Licensing and Investigations Section of the Department of Public Health for the purpose of conducting a complaint investigation (#23648).
Complaint Details
Complaint investigation #23648 was conducted. The findings were initially cited but later rescinded after review and discussion with legal counsel and corporate nurse. The Department of Public Health agreed to rescind the violations cited and no plan of correction was required.
Findings
The agency failed to ensure accurate reconciliation of narcotics for one client requiring nursing management of narcotics. Specifically, discrepancies were found in the narcotic counts and documentation processes, including failure to identify accuracy and safety of narcotic reconciliation.
Deficiencies (1)
Failed to ensure accurate reconciliation of narcotics for one client requiring nursing management of narcotics, including inaccurate narcotic counts and failure to identify accuracy and safety of narcotic reconciliation.
Report Facts
Narcotic tablets counted: 60
Narcotic tablets verified: 30
Clients reviewed: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Loan Nguyen | Supervising Nurse Consultant | Named in relation to the complaint investigation and violation letter. |
| Mary Sullivan | Supervisor of Assisted Living Services Agency | Personnel contacted during inspection and recipient of violation letters. |
| Shawn Montroiani | Senior ED | Personnel contacted during inspection. |
| Joyce Stuber | Regional Nurse | Personnel contacted during inspection. |
| LPN #1 | Licensed Practical Nurse | Involved in narcotic count discrepancy and reconciliation failure. |
| LPN #2 | Licensed Practical Nurse | Involved in narcotic count verification. |
Inspection Report
Renewal
Census: 124
Deficiencies: 8
Date: Jan 5, 2017
Visit Reason
The inspection was conducted as a renewal visit with a complaint investigation (#20378) to assess compliance with Connecticut State regulations.
Complaint Details
Complaint investigation #20378 was conducted. Violations were substantiated as noted in the attached violation letter dated November 2, 2017.
Findings
Violations of Connecticut State regulations were identified during the inspection, including failures in clinical service records related to mechanical lift transfers, communication with home health agencies, notification of responsible parties, and documentation of client mobility status and skin integrity.
Deficiencies (8)
Failure to provide necessary services for a client requiring mechanical lift transfers.
Failure to identify development of a memorandum of understanding with the home health agency to delineate responsibilities.
Failure to notify the client's responsible party regarding ripped lift pad and inability to transfer client out of bed.
Failure to notify the physician of decision to maintain client on bedrest after transfer pad was ripped.
Failure to update plan of care to reflect client's new bedbound status and schedule for repositioning.
Failure to identify documentation reflecting client's actual mobility status during bedbound period.
Failure to demonstrate accurate or authentic documentation of client's mobility status and care provided.
Failure to notify physician and responsible party of skin breakdown and abrasion.
Report Facts
Census: 124
Inspection dates: Inspection conducted on January 5 and 9, 2017.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Sullivan | Supervisor of Assisted Living Services Agency | Personnel contacted during inspection. |
| Loan Nguyen | Supervising Nurse Consultant | Report submitted and violation letter signed. |
| Barbara J. Camillo | Executive Director | Submitted plan of correction letter. |
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Jul 1, 2016
Visit Reason
Unannounced visits were made on July 1, 6, and 7, 2016 to BAL East Haven by the Department of Public Health for the purpose of conducting multiple investigations related to complaints #20196 and #19848.
Complaint Details
Complaint investigations #20196 and #19848 were the basis for the inspection. Violations of the Public Health Code were identified and a violation letter dated 10/28/16 was issued. The complaints involved medication management failures and inadequate care for clients with complex medical needs.
Findings
The Assisted Living Services Agency (ALSA) failed to provide necessary services for two clients requiring medication management and assistance with activities of daily living. Deficiencies included failure to document medication administration properly, failure to reorder prescribed medications timely, and inadequate nursing accountability. Additional findings involved improper handling of a client with bleeding and failure to follow proper invasive procedure protocols.
Deficiencies (5)
Failure to identify nursing accountability for medication administration omissions and failure to document administration or unavailability of medications for Client #1.
Failure to reorder prescribed eye drops for three months and failure to document administration accurately for Client #1.
Failure to provide necessary services including dressing, hygiene, grooming, transfer, and medication management for Client #2.
Failure to follow proper procedures for straight catheterization and bladder scanning for Client #2, resulting in unsuccessful invasive procedures and lack of policy adherence.
Failure to properly monitor and respond to bleeding and injury in Client #2, including inadequate documentation and failure to notify appropriate parties.
Report Facts
Dates of onsite inspection: July 1, 6, and 7, 2016
Client #1 admission date: October 5, 2013
Client #1 medication service program period: February 23, 2016 through June 22, 2016
Client #2 start of care date: September 3, 2015
Plan of correction effective date: November 30, 2016
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Peter Marinelli | Executive Director | Personnel contacted during inspection and service coordinator for Managed Residential Community. |
| Valerie Vargas | Supervisor of Assisted Living Services Agency | Named in violation letter and inspection contact. |
| Loan Nguyen | Supervising Nurse Consultant | Author of violation letter and report approval. |
| Barbara J. Camillo | Executive Director | Submitted prospective plan of correction letter. |
| LPN #1 | Counseled and received written warning related to medication administration deficiencies. |
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