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
43210
2022
2023
2024
Census
Latest occupancy rate18 residents
Based on a April 2023 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
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.
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
Name
Title
Context
Michael J. Smith
Nurse Consultant
Signature of FLIS staff conducting the inspection and submitting the report.
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.
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.
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, 2023Elopement incident date: Mar 10, 2023Client admission date: Jan 21, 2023Client nursing assessment date: Feb 27, 2023Alarm release time: 15Panic bar lock release extension: 30Deadline for corrective measures: May 31, 2023Deadline for elopement risk assessments: Jun 15, 2023Deadline 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 LicensingCapacity: 112Deficiencies: 0Dec 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: 112Census: 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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