Inspection Reports for All American Assisted Living at Enfield

CT, 06082

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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/year

Deficiencies per year

4 3 2 1 0
2022
2023
2024

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

0 30 60 90 120 Dec 2022 Apr 2023
Inspection Report Complaint Investigation Deficiencies: 0 Jun 26, 2024
Visit Reason
The inspection was conducted as a complaint investigation related to Complaint #39541.
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 #39541 was the reason for the visit; violations were identified.
Employees Mentioned
NameTitleContext
Michael J. SmithNurse ConsultantSignature of FLIS Staff and report submitter
Valerie RomanoDumaisExecutivePersonnel contacted during inspection
Dana ArcouetteSALSAPersonnel contacted during inspection
Inspection Report Complaint Investigation Deficiencies: 0 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.
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.
Complaint Details
Complaint investigation #39541 was the reason for the visit. Specific substantiation status is not stated.
Employees Mentioned
NameTitleContext
Michael J. SmithNurse ConsultantSignature of FLIS staff conducting the inspection and submitting the report.
Valerie Romano DumaisExecutivePersonnel contacted during the inspection.
Dana ArcouetteSALSAPersonnel contacted during the inspection.
Inspection Report Monitoring Deficiencies: 0 Oct 17, 2023
Visit Reason
The inspection was conducted as a strike monitoring visit related to Complaint Investigation #34943.
Findings
The report does not provide detailed findings or deficiencies; it is a licensing inspection supplement for strike monitoring purposes.
Complaint Details
Visit was related to Complaint Investigation #34943; no substantiation status provided.
Employees Mentioned
NameTitleContext
Megan Edson-SawyerSurvey Team Leader / Nurse ConsultantNamed as Survey Team Leader and Report Submitter.
Elizabeth HeineySupervisorNamed as Supervisor.
Annie StonePersonnel contacted during inspection.
Inspection Report Complaint Investigation Deficiencies: 0 Oct 17, 2023
Visit Reason
The inspection visit was conducted as a complaint investigation identified by Complaint Investigation #34943.
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.
Complaint Details
Complaint Investigation #34943 was substantiated with violations found during the inspection.
Employees Mentioned
NameTitleContext
Annie StonePersonnel contacted during the inspection.
Megan Edson-SawyerSurvey Team LeaderNamed as Survey Team Leader for the inspection.
Elizabeth HeineySupervisorNamed as Supervisor for the inspection.
Inspection Report Monitoring Census: 18 Deficiencies: 0 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
NameTitleContext
Peg SullivanExecutive DirectorInterviewed during the monitoring visit
Megan Edson-SawyerNurse ConsultantSignature of FLIS Staff and report submitter
Inspection Report Monitoring Deficiencies: 1 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)
Description
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
NameTitleContext
Elizabeth HeineySupervising Nurse ConsultantAuthor of the initial violation letter and contact for plan of correction
Peg SullivanExecutive DirectorNamed in relation to the elopement incident and plan of correction submission
Yvette HassettResident Care DirectorResponsible staff member for ensuring compliance with plan of correction
Megan Edson-SwayerRNConducted the unannounced Monitoring Re-Visit
Inspection Report Original Licensing Capacity: 112 Deficiencies: 0 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
NameTitleContext
Peg SullivanExecutive DirectorPersonnel contacted during inspection.
Jaimie GirardRegional VP of OperationsPersonnel contacted during inspection.
Yvette HassettSALSAPersonnel contacted during inspection.
Elizabeth T HeineySNCReport submitted by.

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