Inspection Report Summary
The most recent inspection on November 13, 2023, was a complaint investigation that found no deficiencies. Earlier inspections showed a pattern of deficiencies related primarily to client care issues, including failure to ensure clients were free from abuse and neglect, inadequate pain management, and medication administration errors. Some investigations substantiated complaints about these care concerns, and inspectors cited failures in coordination with hospice services and documentation of complaint resolutions. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility’s inspection history indicates improvement over time, with the most recent visits showing no deficiencies after prior citations.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
2.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
55% better than Connecticut average
Connecticut average: 5.6 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
78% occupied
Based on a November 2021 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Nov 13, 2023
Visit Reason
The inspection visit was conducted as a complaint investigation related to Connecticut complaint CT #35882.
Complaint Details
Complaint investigation CT #35882 was the reason for the visit; no violations were found.
Findings
No violations of the General Statutes of Connecticut and/or regulations of Connecticut State Agencies were identified at the time of this inspection.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Karen Donato | RN Nurse Consultant | Report submitted by and signature on inspection report. |
| Annette Cochefski | Personnel contacted: Executive Director. | |
| Colleen Cavanaugh | Personnel contacted: SALSA. |
Inspection Report
Renewal
Census: 84
Capacity: 108
Deficiencies: 0
Date: Nov 4, 2021
Visit Reason
The inspection was conducted as a licensing inspection for renewal purposes to assess compliance with regulations and licensing requirements.
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: 108
Census: 84
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Colleen Cavanaugh | RN SALSA | Personnel contacted during inspection |
| Laura Boggio | Survey Team Leader | Survey team leader for the inspection |
| Cheryl Davis | Supervisor | Supervisor for the inspection |
Inspection Report
Routine
Deficiencies: 0
Date: Mar 15, 2021
Visit Reason
The visit was conducted for a COVID-19 focused infection control survey to review the effectiveness of the Infection Prevention and Control Program and related COVID-19 protocols.
Findings
No deficiencies were identified during the survey. Observations included staff performing hand hygiene, clients wearing facemasks, and review of dining and recreational activity processes.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Megan Edson-Sawyer | Nurse Consultant | Conducted the inspection and submitted the report. |
| Justin Grady | Executive Director | Personnel contacted during the inspection. |
Inspection Report
Routine
Deficiencies: 0
Date: Mar 15, 2021
Visit Reason
An unannounced onsite visit was conducted for a COVID-19 focused survey to review the effectiveness of the Infection Prevention and Control Program and related COVID-19 protocols.
Findings
No deficiencies were identified as a result of this survey. The review included client care quality, PPE supply, staff and resident COVID-19 testing, visitor restrictions, staff screening, environmental cleaning, and observation of staff and clients.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Megan Edson-Sawyer | Nurse Consultant | Conducted and submitted the licensing inspection report. |
| Justin Grady | Executive Director | Personnel contacted during the inspection. |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Nov 23, 2020
Visit Reason
An unannounced visit was made to BAL Middletown on November 23, 2020 by a representative of the Facility Licensing and Investigations Section of the Department of Public Health for the purpose of conducting an investigation.
Findings
Violations of the Regulations of Connecticut State Agencies and/or General Statutes were identified related to failure to ensure clients' needs were met and failure to ensure clients were free from abuse and neglect. Specific findings include incidents of yelling by an ALSA aide and failure to provide assistance and protection to clients as required by the plan of care.
Deficiencies (1)
Failure to ensure the client's needs were met and failure to ensure the clients were free from abuse and neglect, including incidents of yelling by ALSA aide and failure to provide assistance and protection to clients.
Report Facts
Date of visit: Nov 23, 2020
Date of plan of correction submission deadline: Dec 10, 2020
Client admission date: Jul 28, 2019
Client admission date: Feb 29, 2020
Date of client service program: Jun 12, 2020
Date of client service program: Jun 11, 2020
Date of ALSA documentation: Sep 29, 2020
Date of termination of NA #1: Oct 4, 2020
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Loan Nguyen | Supervising Nurse Consultant | Signed letter regarding violations and plan of correction |
| Joel Garcia | RN, BSN | Signed Plan of Correction document |
Inspection Report
Plan of Correction
Deficiencies: 5
Date: Sep 19, 2020
Visit Reason
Unannounced visits were made to BAL Middletown on September 19 and 21, 2020 by the Department of Public Health for the purpose of conducting an investigation into violations of Connecticut State Agencies regulations and General Statutes.
Complaint Details
The investigation was complaint-related, focusing on the lack of pain management for Client #1 and failure to resolve complaints regarding mismanagement of the client's pain. The complaint was substantiated by findings of inadequate pain management and failure to document complaint resolution.
Findings
The Assisted Living Services Agency (ALSA) failed to coordinate with the hospice agency, physician, and family to provide comfort and dignity to hospice clients and failed to conduct a comprehensive complaint investigation. Specific issues included lack of licensed nurses during night shifts, inadequate pain management, failure to document complaint resolution, and failure to implement a comprehensive written agreement delineating responsibilities between ALSA and the hospice agency.
Deficiencies (5)
Failure to coordinate with hospice agency, physician, and family to provide comfort and dignity to hospice clients and failure to conduct a comprehensive complaint investigation.
Failure to employ licensed nurses during the night shift.
Failure to manage client's pain at night and failure to ensure administration of narcotic analgesic during the night.
Failure to provide written documentation of interviews and/or statements and failure to document resolution of complaint.
Failure to have a comprehensive written agreement (MOU) delineating responsibilities of ALSA and hospice agency.
Report Facts
Dates of visit: 2
Medication dose: 650
Medication dose: 5
Medication dose: 1000
Dates: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Loan Nguyen | Supervising Nurse Consultant | Signed the report and contact for questions |
| Joel Garcia | RN, BSN | Listed as contact on Plan of Correction |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jul 27, 2020
Visit Reason
An unannounced visit was made to BAL Middletown on July 27, 2020 by a representative of the Facility Licensing and Investigations Section of the Department of Public Health for the purpose of conducting an investigation.
Findings
Violations of Connecticut State Agencies regulations were identified related to failure to ensure clients' needs were met, protection from abuse and neglect, and failure to develop and implement a process for remediation and monitoring of ALSA aides. Specific incidents involving two clients and an ALSA aide were documented, including failure to provide hygiene care and abusive behavior by the aide.
Deficiencies (1)
ALSA failed to ensure clients were free from abuse and neglect and failed to develop and implement a process for remediation and monitoring the ALSA aide to prevent further incidents.
Report Facts
Date of visit: Jul 27, 2020
Plan of correction submission deadline: Aug 17, 2020
Number of clients involved in findings: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Loan Nguyen | Supervising Nurse Consultant | Signed letter and contact for questions regarding violations |
Inspection Report
Plan of Correction
Deficiencies: 3
Date: Aug 6, 2019
Visit Reason
Unannounced visits were made to Bal Middletown on October 9, 2018, January 2, 2019 and August 6, 2019 by representatives of the Facility Licensing and Investigations Section of the Department of Public Health for the purpose of conducting multiple investigations.
Findings
Violations of the Regulations of Connecticut State Agencies and/or General Statutes were identified related to medication administration, client service records, protection from abuse and misappropriation of property by assisted living services agency staff. Specific deficiencies included failure to administer medications as ordered, failure to assess clients and notify responsible parties of condition changes, and failure to protect clients from abuse and misappropriation of property.
Deficiencies (3)
ALSA aides failed to provide needed care and failed to administer medications as ordered by the physician.
Failure to ensure assessment of the client and notification of the responsible party following a change in condition.
Failure to protect clients from abuse and misappropriation of property by ALSA staff.
Report Facts
Dates of visits: October 9, 2018, January 2, 2019, August 6, 2019
Number of clients in survey sample: 6
Number of clients with abuse/misappropriation findings: 3
Medication doses administered: 7
Missing money amounts: 83
Missing money amounts: 20
Missing money amounts: 50
Missing money amounts: 200
Missing money amounts: 300
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Loan Nguyen | Supervising Nurse Consultant | Signed the notice of violations letter |
| Joel Garcia | Supervisor of Assisted Living Services Agency | Recipient of the notice of violations and plan of correction |
Inspection Report
Complaint Investigation
Census: 91
Capacity: 91
Deficiencies: 0
Date: Jan 7, 2019
Visit Reason
The inspection was conducted as a complaint investigation related to violations of the General Statutes of Connecticut and/or regulations of Connecticut State Agencies.
Complaint Details
Complaint investigation number 20318 was the reason for the visit. Violations were found during the inspection.
Findings
Violations were identified at the time of the inspection. The report includes findings related to the complaint investigation and notes approval for issuance of license.
Report Facts
Licensed Bed Capacity: 91
Census: 91
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ryan Uhlman | Registered Nurse | Personnel contacted during inspection |
| Sheryl Johnson | SALSA | Personnel contacted during inspection |
| Paige Menditto | Registered Nurse | Personnel contacted during inspection |
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