Inspection Report Summary
The most recent inspection on July 15, 2024 identified deficiencies related to quality of care, supervisory nursing oversight, and respect for a client’s dignity in incontinence care management. Earlier inspections also noted deficiencies involving care supervision, documentation, and regulatory compliance, including substantiated complaints of verbal and physical abuse by staff and incomplete disclosure agreements for the Memory Care Unit. Complaint investigations found violations related to client care and administrative oversight, with one substantiated case involving abuse and others related to incomplete or missing documentation. Enforcement actions such as fines or license suspensions were not listed in the available reports. The pattern of deficiencies suggests ongoing challenges with care supervision and regulatory compliance, with no clear trend of improvement or worsening over time.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
64% better than Connecticut average
Connecticut average: 5.6 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
159% occupied
Based on a July 2024 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Plan of Correction
Deficiencies: 1
Jul 15, 2024
Visit Reason
An unannounced visit was made to Addison Place At Glastonbury on July 15, 2024 by a representative of the Facility Licensing and Investigations Section of the Department of Public Health for the purpose of conducting an investigation.
Findings
The Assisted Living Service Agency (ALSA) failed to ensure quality of care, supervisory nursing oversight, and that the client was treated with respect and dignity related to incontinence care management. Specific incidents included a client found with fecal matter on their body and surroundings, and improper transfer techniques causing discomfort.
Complaint Details
The visit was complaint-related as indicated by Complaint CT #39914. The complaint involved observations and video evidence of inadequate care and improper handling of a client by agency aides, resulting in discomfort and dignity concerns.
Deficiencies (1)
| Description |
|---|
| Failure to ensure quality of care and supervisory nursing oversight in delivery of services and care needs to client, and failure to ensure client was treated with respect and dignity related to incontinence care management. |
Report Facts
Days to complete inservices: 60
Nursing rounds frequency: 2
Nursing rounds decrease to: 20
Nursing rounds decrease to: 10
Resident rounds QA meeting frequency: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Marty Sawyer | Resident Care Director | Signed the Plan of Correction letter. |
| Elizabeth T. Heiney | Supervising Nurse Consultant | Recipient of the Plan of Correction and author of the violation letter. |
| Sandra Carlmark | Executive Director | Addison Place At Glastonbury Executive Director addressed in the violation letter. |
Inspection Report
Complaint Investigation
Census: 81
Capacity: 51
Deficiencies: 0
Jul 15, 2024
Visit Reason
The inspection visit was conducted as a complaint investigation identified by CT#39914, to assess violations of the General Statutes of Connecticut and/or regulations of Connecticut State Agencies.
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.
Complaint Details
Complaint investigation CT#39914 was conducted and violations were found.
Report Facts
Memory care capacity: 17
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sandra Carlmark | Executive | Personnel contacted during inspection |
| Michael J. Smith | Nurse Consultant | Signature of FLIS Staff and report submitted by |
Inspection Report
Renewal
Census: 74
Capacity: 81
Deficiencies: 0
May 8, 2024
Visit Reason
The inspection was conducted as a licensing inspection for renewal purposes and included review of a complaint investigation (37615).
Findings
Violations of the General Statutes of Connecticut and/or regulations of Connecticut State Agencies were identified during the inspection. The report references an attached violation letter dated 2024-05-15.
Complaint Details
The visit included review of complaint investigation number 37615.
Report Facts
Census: 74
Total Capacity: 81
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Elizabeth T Heiney | SNC Nurse Consultant | Signature of FLIS staff and report submitter |
| Sandra Calmark | ED | Personnel contacted during inspection |
| Martha Sawyer | SALSA | Personnel contacted during inspection and Part Time Infection Prevention and Control Specialist |
Inspection Report
Renewal
Census: 74
Capacity: 81
Deficiencies: 0
May 8, 2024
Visit Reason
The inspection was conducted as a licensing renewal inspection for Addison Place at Glastonbury, including review of compliance with Connecticut state statutes and regulations.
Findings
Violations of the General Statutes of Connecticut and/or regulations were identified during the inspection. A violation letter dated 2024-05-21 was attached to the report.
Report Facts
Memory Care/Traditional beds: 17
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Elizabeth T Heiney | SNC Nurse Consultant | Report submitted by and signature on inspection report |
| Sandra Calmark | ED | Personnel contacted during inspection |
| Martha Sawyer | SALSA RN | Personnel contacted and Part Time Infection Prevention and Control Specialist |
Inspection Report
Complaint Investigation
Census: 74
Capacity: 81
Deficiencies: 1
May 8, 2024
Visit Reason
An unannounced visit was made to Addison Place At Glastonbury on May 8, 2024, for the purpose of conducting an investigation and a licensure renewal inspection, triggered by Complaint Investigation #37615.
Findings
Violations of Connecticut General Statutes and regulations were identified, including failure to ensure completion of the Dementia Special Care Unit/Memory Care Unit disclosure agreement for 7 of 17 clients residing in the Memory Care Unit. The Executive Director and Business Manager confirmed missing disclosures and incomplete financial files for some clients.
Complaint Details
Complaint Investigation #37615 was the basis for the visit. The report does not explicitly state substantiation status.
Deficiencies (1)
| Description |
|---|
| Failure to ensure completion of the Dementia Special Care Unit/Memory Care Unit disclosure agreement for 7 of 17 clients residing in the Memory Care Unit. |
Report Facts
Census: 74
Total Capacity: 81
Memory Care Capacity: 17
Clients reviewed: 17
Clients with missing disclosures: 7
Clients currently residing in Dementia Special Care Unit: 18
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Elizabeth T Heiney | Supervising Nurse Consultant | Report submitted by and contact for plan of correction |
| Sandra Calmark | Executive Director | Personnel contacted and named in findings regarding missing disclosures |
| Martha Sawyer | Part Time Infection Prevention and Control Specialist | Personnel contacted |
Inspection Report
Plan of Correction
Deficiencies: 1
Apr 4, 2024
Visit Reason
Unannounced visits were made to HarborChase Of Evergreen Walk concluding on April 4, 2024, by a representative of the Facility Licensing and Investigations Section of the Department of Public Health to conduct an investigation with additional information received through April 8, 2024.
Findings
The agency failed to supervise the care and services provided by the assisted living aide, resulting in verbal and physical abuse of a client. The aide was observed providing care in a rough manner, making unprofessional comments, and causing pain to the client. The aide was terminated, but the agency failed to ensure the safety and rights of the client and oversight of aide staff.
Complaint Details
Complaint CT #38228 involved allegations of verbal and physical abuse by an assisted living aide toward Client #1. The complaint was substantiated based on interviews and agency investigation documentation.
Deficiencies (1)
| Description |
|---|
| Failure to supervise the care and services provided by the assisted living aide, resulting in verbal and physical abuse of a client. |
Report Facts
Clients served by ALSA: 5
Plan of correction submission deadline: 2024
Audit completion date: 2024
Percentage of charts audited monthly: 10
Supervision period: 120
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Elizabeth T. Heiney | Supervising Nurse Consultant | Author of the letter and contact for plan of correction response |
| Stacey Pellingra | Executive Director | Named in letter as Executive Director of HarborChase Of Evergreen Walk |
| Katherine Madigan | RN, Supervisor of Assisted Living Services | Responsible for auditing abuse policy training and aide supervision compliance |
Inspection Report
Monitoring
Census: 76
Capacity: 81
Deficiencies: 0
Jul 11, 2022
Visit Reason
The inspection visit was conducted as a strike monitoring supplement to the licensing inspection report.
Findings
The report does not provide detailed findings or deficiencies within the extracted text and images. No violations or citations are explicitly stated in the provided content.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sandra Carlmark | ED | Personnel contacted during the inspection. |
| Mary Sawyer | SALSA | Personnel contacted during the inspection. |
Inspection Report
Complaint Investigation
Deficiencies: 4
Jan 21, 2021
Visit Reason
An unannounced visit was made to Addison Place At Glastonbury on January 21, 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 #29106.
Findings
The Assisted Living Services Agency (ALSA) failed to orient private help staff to emergency policies and CDC guidelines for COVID-19 prevention. Observations included improper mask wearing by private help and a nurse designee failing to properly use personal protective equipment (PPE) and hand hygiene. The facility's policies and documentation related to COVID-19 orientation and PPE use were found deficient.
Complaint Details
Complaint #29106 triggered the investigation. The report does not explicitly state substantiation status.
Deficiencies (4)
| Description |
|---|
| Failure to orient private help to ALSA's emergency policies and CDC COVID-19 guidelines, including proper mask wearing. |
| Private Help #1 wore surgical mask covering mouth but not nose and wore KN95 mask improperly with bottom loop dangling under chin. |
| Nurse Designee left client room without doffing PPE and touched multiple surfaces without hand sanitizer use. |
| Failure to identify orientation by ALSA to private help of client’s plan of care, emergency policies related to COVID-19, and documentation of such orientation. |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Karen Donato | Supervising Nurse Consultant/Interim | Signed the violation letter and conducted the complaint investigation. |
| Beth Prevo | Executive Director | Named in the Plan of Correction letter responding to the complaint. |
| Megan Edson-Sawyer | Nurse Consultant | Recipient of the Plan of Correction letter. |
Inspection Report
Original Licensing
Deficiencies: 1
Sep 6, 2020
Visit Reason
An unannounced visit was made to Addison Place in Glastonbury on September 6, 2020 by a representative of the Facility Licensing and Investigations Section of the Department of Public Health for the purpose of conducting a licensing inspection.
Findings
The Assisted Living Services Agency (ALSA) failed to ensure all staff were tested on a weekly basis before determining negative status for a minimum of 14 days and entering a pause of testing, in accordance with the Governor's Executive Order. The facility did not include all employees in weekly testing rosters and failed to accurately track comprehensive weekly testing prior to pausing testing on 7/13/2020.
Deficiencies (1)
| Description |
|---|
| ALSA failed to ensure all staff were tested weekly before determining negative status for a minimum of 14 days and entering a pause of testing, missing inclusion of several employees in testing rosters and failing to track comprehensive weekly testing. |
Report Facts
Date of visit: Sep 6, 2020
Testing dates: 3
Employees not included in testing on 7/6/2020: 3
Employees not included in testing on 7/13/2020: 6
Testing duration: 14
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Loan Nguyen | Supervising Nurse Consultant | Signed letter and contact for questions |
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