Inspection Report Summary
The most recent inspection on December 19, 2023, identified deficiencies related to failure to notify and assess a client after a fall and failure to ensure the client was free from neglect. Earlier inspections also noted violations involving client safety, medication administration, and oversight, including substantiated complaints about abuse reporting and narcotic documentation. The main themes across reports included client safety concerns, medication management issues, and regulatory compliance with Alzheimer’s care unit requirements. Complaint investigations were mostly substantiated when violations were found, with one notable case involving client-to-client abuse in the memory care unit. The facility’s inspection history shows ongoing challenges with safety and medication oversight, with no clear pattern of consistent improvement over time.
Deficiencies (last 5 years)
Deficiencies (over 5 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
88% occupied
Based on a February 2023 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Deficiencies: 0
Dec 19, 2023
Visit Reason
The inspection visit was conducted as a complaint investigation related to Complaint Investigation CT #36820 and to verify compliance with Alzheimer's special care unit requirements and infection prevention and control standards.
Findings
Violations of the General Statutes of Connecticut and/or regulations were identified at the time of inspection. Verification of Alzheimer's special care units and full-time Infection Prevention and Control Specialist requirements were also conducted.
Complaint Details
Complaint Investigation CT #36820 was the basis for the visit. Specific substantiation status is not provided.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Karen Donato | Nurse Consultant | Report submitted by |
| Ingrid Kausyla | Executive Director | Personnel contacted during inspection |
| Holly Breault | SALSA | Personnel contacted during inspection |
Inspection Report
Plan of Correction
Deficiencies: 3
Dec 19, 2023
Visit Reason
An unannounced visit was made to Brandywine Living At Litchfield on December 19, 2023 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 of Connecticut were noted during the visit. The report includes a plan of correction submitted by the facility addressing failure to notify a registered nurse after a fall and failure to assess the client after a fall.
Complaint Details
Complaint #36820 was investigated as part of this visit.
Deficiencies (3)
| Description |
|---|
| Failure to notify RN on call after a fall. |
| Failure of RN to assess the client after a fall. |
| Failure to ensure the client was free from neglect. |
Report Facts
Plan of correction submission deadline: 10
Plan of correction review deadline: 26
Date of incident: Nov 30, 2023
Date of visit: Dec 19, 2023
Time client found on floor: 430
Safety check interval: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Elizabeth Heiney | Supervising Nurse Consultant | Signed letter and contact for questions concerning instructions |
Inspection Report
Renewal
Census: 30
Capacity: 34
Deficiencies: 0
Feb 6, 2023
Visit Reason
The inspection visit was conducted as a renewal licensing inspection of the Brandywine Living at Litchfield facility to verify compliance with Connecticut state regulations and statutes.
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 completed.
Report Facts
Memory Care/Traditional Census: 30
Memory Care/Traditional Capacity: 34
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ingrid Kausyla | Executive Director | Personnel contacted during inspection |
| Jina Lafleur | SALSA | Personnel contacted during inspection |
Inspection Report
Renewal
Deficiencies: 0
Feb 6, 2023
Visit Reason
An unannounced visit was made to Brandywine Living At Litchfield on February 6, 2023 by a representative of the Facility Licensing and Investigations Section of the Department of Public Health for the purpose of conducting a licensure renewal inspection.
Findings
Violations of the Regulations of Connecticut State Agencies and/or General Statutes of Connecticut were noted during the visit. The state violations cannot be edited by the provider in any way.
Report Facts
Plan of correction submission deadline: 2023
Plan of correction submission deadline day: 9
Plan of correction submission deadline month: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Elizabeth T. Heiney | Supervising Nurse Consultant | Named as contact for response to violations and instructions |
| Jina Lafleur | Health and Wellness Director | Signed the plan of correction and named as responsible staff member |
Inspection Report
Complaint Investigation
Deficiencies: 1
Jul 8, 2022
Visit Reason
An unannounced visit was made to Brandywine Living At Litchfield on July 8, 2022, by a representative of the Department of Public Health to conduct a Complaint Investigation to determine Verification of Alzheimer's special care units or programs.
Findings
The investigation found multiple violations related to failure to ensure client safety, including failure to report allegations of abuse, failure to update client service plans, failure to complete assessments, and failure to notify law enforcement and regulatory agencies of suspected abuse. The findings involved five clients in the Assisted Living Services Agency memory care unit and included incidents of client-to-client abuse and inadequate care coordination.
Complaint Details
Complaint #32457 was investigated. The findings included substantiated failures in client safety and abuse reporting in the Assisted Living Services Agency memory care unit.
Deficiencies (1)
| Description |
|---|
| Failure to ensure Clients safety including failure to report allegations of abuse, failure to update client service plans, failure to complete assessments, and failure to notify law enforcement and regulatory agencies. |
Report Facts
Complaint number: 32457
Number of clients involved: 5
Date of inspection visit: Jul 8, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Elizabeth Heiney | Supervising Nurse Consultant | Signed letter regarding complaint investigation and plan of correction instructions |
| Kelly Bieber | VP of Nursing | Recipient of the complaint investigation letter |
Inspection Report
Complaint Investigation
Deficiencies: 0
Jul 8, 2022
Visit Reason
The inspection visit was conducted as a complaint investigation related to Complaint CT#32547.
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 or programs was also conducted.
Complaint Details
Complaint Investigation CT#32547 was the reason for the visit. Violations were identified during the inspection.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Robin Vaughn | Executive Director | Personnel contacted during the inspection. |
| Mermisa Carney | Personnel contacted during the inspection. | |
| Megan Edson-Sawyer | Nurse Consultant | Signature of FLIS Staff and report submitter. |
Inspection Report
Complaint Investigation
Census: 73
Capacity: 102
Deficiencies: 0
May 18, 2022
Visit Reason
The inspection was conducted as a complaint investigation related to CT #32158.
Findings
No violations of the General Statutes of Connecticut and/or regulations of Connecticut State Agencies were identified at the time of this inspection.
Complaint Details
Complaint investigation CT #32158 was conducted and found no violations; the complaint was not substantiated.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Karen Donato | Nurse Consultant | Signature of FLIS Staff and report submitted by |
| Mermisa Carney | Personnel contacted SALSA | |
| Robin Vaughn | ED | Personnel contacted |
Inspection Report
Plan of Correction
Deficiencies: 1
Sep 20, 2021
Visit Reason
Unannounced visits were made to Brandywine Living At Litchfield on September 17 and 20, 2021 for the purpose of conducting a licensing inspection renewal and complaint investigation.
Findings
The inspection identified violations related to the failure of an Assisted Living Services Agency (ALSA) nurse to document narcotics administration according to ALSA policies and procedures, and lack of oversight of narcotics administration. Multiple clients' records showed failures in documentation of narcotic administration and medication errors, leading to an investigation and corrective actions.
Complaint Details
Complaint #30454 triggered the investigation. The complaint was substantiated as violations were identified related to narcotic administration documentation and oversight.
Deficiencies (1)
| Description |
|---|
| Failure to document narcotics administration in accordance with ALSA policies and procedures and failure to provide oversight of narcotics administration to clients by agency nurses. |
Report Facts
Clients reviewed: 5
Plan of correction submission deadline: Oct 29, 2021
Effective date of plan of correction: Jul 20, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Cheryl Davis | Public Health Services Manager | Signed letter as Facility Licensing and Investigations Section (FLIS) representative. |
| LPN #1 | Failed to document narcotic administration for multiple clients and was relieved of duties at ALSA. | |
| RN Designee | Registered Nurse | Identified documentation failures and initiated investigation. |
| DEA Agent #1 | Conducted subsequent investigation on 09/22/21 related to narcotic administration documentation. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Feb 6, 2020
Visit Reason
Unannounced visits were made to Brandywine Assisted Living At Litchfield on February 6, 2020, 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 February 25, 2020.
Findings
Violations of Connecticut State Agencies regulations were identified related to failure to ensure comprehensive safety measures to prevent elopement of a client, and failure to provide oversight, education, and comprehensive investigation of narcotic discrepancies by Assisted Living Services Agency nurses and supervisors.
Complaint Details
The investigation was complaint-related, triggered by incidents including a client eloping from the facility for six hours and narcotic discrepancies involving liquid Ativan and Morphine. The report does not explicitly state substantiation status.
Deficiencies (2)
| Description |
|---|
| Failure to ensure the development of comprehensive safety measures to prevent elopement of a client who eloped for six hours and exhibited exit seeking behaviors. |
| Failure of Assisted Living Services Agency nurses to follow agency policies and failure of supervisors to provide oversight, education, and complete a comprehensive investigation of narcotic discrepancies. |
Report Facts
Visit dates: 3
Hours client eloped: 6
Missing milliliters: 9
Missing milliliters: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Loan Nguyen | Supervising Nurse Consultant | Signed the initial violation letter and involved in interviews |
| Julie Troy | Wellness Director | Named in plan of correction response and involved in narcotic count policy enforcement |
Inspection Report
Complaint Investigation
Deficiencies: 2
Feb 6, 2020
Visit Reason
Unannounced visits were made to Brandywine Assisted Living At Litchfield on February 6, 2020, to conduct an investigation following complaints received through February 25, 2020.
Findings
Two violations of Connecticut State Agencies regulations were identified: 1) Failure to ensure comprehensive safety measures to prevent elopement of a client who eloped for six hours, including inadequate door security and monitoring; 2) Failure to provide oversight, education, and a comprehensive investigation of narcotic discrepancies for a client receiving symptom management, including improper narcotic counts and documentation.
Complaint Details
The investigation was complaint-driven, triggered by reports of a client eloping for six hours and narcotic management concerns. The complaint was substantiated with findings of safety and medication management violations.
Deficiencies (2)
| Description |
|---|
| Failure to ensure development of comprehensive safety measures to prevent elopement of a client who eloped for six hours. |
| Failure to provide oversight, education, and complete investigation of narcotic discrepancies, including failure to follow agency policies and incomplete narcotic counts. |
Report Facts
Visit dates: 3
Elopement duration: 6
Narcotic audit frequency: 100
Missing narcotic volume: 9
Missing narcotic volume: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Julie Troy | Wellness Director | Signed the Plan of Correction response letter. |
| Loan Nguyen | Supervising Nurse Consultant | Recipient of the violation letter and Plan of Correction. |
Inspection Report
Plan of Correction
Deficiencies: 1
Mar 13, 2019
Visit Reason
An unannounced visit was made to Brandywine Assisted Living At Litchfield on March 13, 2019 by a representative of the Facility Licensing and Investigations Section of the Department of Public Health for the purpose of conducting an investigation.
Findings
A violation was identified regarding the failure to ensure an employee carried a valid nursing license. Specifically, one Licensed Practical Nurse (LPN #1) continued to work for a year after the expiration of their nursing license, and the facility failed to have a proper system to track and identify expired nursing licenses.
Deficiencies (1)
| Description |
|---|
| Failure to ensure the employee carried a valid license to practice nursing in Connecticut; LPN #1 worked for a year after license expiration and the facility lacked a system to track expired licenses. |
Report Facts
Date of visit: Mar 13, 2019
License expiration date: Apr 30, 2018
Reinstatement order date: Aug 30, 2018
Plan of correction submission deadline: May 2, 2019
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Loan Nguyen | Supervising Nurse Consultant | Author of the violation letter and investigation report |
| Julie Troy | Supervisor of Assisted Living Services Agency / Wellness Director | Recipient of the violation letter and author of the plan of correction |
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