Inspection Reports for
Brandywine Litchfield

CT, 06759

Back to Facility Profile

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/year

Deficiencies per year

4 3 2 1 0
2019
2020
2021
2022
2023

Census

Latest occupancy rate 88% occupied

Based on a February 2023 inspection.

This facility has shown a decline in demand based on occupancy rates.

Occupancy over time

0 30 60 90 120 May 2022 Feb 2023

Inspection Report

Complaint Investigation
Deficiencies: 0 Date: 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.

Complaint Details
Complaint Investigation CT #36820 was the basis for the visit. Specific substantiation status is not provided.
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.

Employees mentioned
NameTitleContext
Karen DonatoNurse ConsultantReport submitted by
Ingrid KausylaExecutive DirectorPersonnel contacted during inspection
Holly BreaultSALSAPersonnel contacted during inspection

Inspection Report

Plan of Correction
Deficiencies: 3 Date: 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.

Complaint Details
Complaint #36820 was investigated as part of this visit.
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.

Deficiencies (3)
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
NameTitleContext
Elizabeth HeineySupervising Nurse ConsultantSigned letter and contact for questions concerning instructions

Inspection Report

Renewal
Census: 30 Capacity: 34 Deficiencies: 0 Date: 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
NameTitleContext
Ingrid KausylaExecutive DirectorPersonnel contacted during inspection
Jina LafleurSALSAPersonnel contacted during inspection

Inspection Report

Renewal
Deficiencies: 0 Date: 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
NameTitleContext
Elizabeth T. HeineySupervising Nurse ConsultantNamed as contact for response to violations and instructions
Jina LafleurHealth and Wellness DirectorSigned the plan of correction and named as responsible staff member

Inspection Report

Complaint Investigation
Deficiencies: 1 Date: 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.

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.
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.

Deficiencies (1)
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
NameTitleContext
Elizabeth HeineySupervising Nurse ConsultantSigned letter regarding complaint investigation and plan of correction instructions
Kelly BieberVP of NursingRecipient of the complaint investigation letter

Inspection Report

Complaint Investigation
Deficiencies: 0 Date: Jul 8, 2022

Visit Reason
The inspection visit was conducted as a complaint investigation related to Complaint CT#32547 and to verify violations of the General Statutes of Connecticut and/or regulations of Connecticut State Agencies.

Complaint Details
Complaint investigation CT#32547 was the reason for the visit. Violations were identified and an attached violation letter dated 9/24/22 was referenced.
Findings
Violations of the General Statutes of Connecticut and/or regulations were identified at the time of the inspection. Verification of Alzheimer's special care units or programs was also conducted.

Employees mentioned
NameTitleContext
Robin VaughnExecutive DirectorPersonnel contacted during the inspection
Mermisa CarneySALSAPersonnel contacted during the inspection
Megan Edson-SawyerNurse ConsultantSignature of FLIS Staff and report submitter

Inspection Report

Complaint Investigation
Census: 73 Capacity: 102 Deficiencies: 0 Date: May 18, 2022

Visit Reason
The inspection was conducted as a complaint investigation related to CT #32158.

Complaint Details
Complaint investigation CT #32158 was conducted and found no violations; the complaint was not substantiated.
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
NameTitleContext
Karen DonatoNurse ConsultantSignature of FLIS Staff and report submitted by
Mermisa CarneyPersonnel contacted SALSA
Robin VaughnEDPersonnel contacted

Inspection Report

Plan of Correction
Deficiencies: 1 Date: 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.

Complaint Details
Complaint #30454 triggered the investigation. The complaint was substantiated as violations were identified related to narcotic administration documentation and oversight.
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.

Deficiencies (1)
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
NameTitleContext
Cheryl DavisPublic Health Services ManagerSigned letter as Facility Licensing and Investigations Section (FLIS) representative.
LPN #1Failed to document narcotic administration for multiple clients and was relieved of duties at ALSA.
RN DesigneeRegistered NurseIdentified documentation failures and initiated investigation.
DEA Agent #1Conducted subsequent investigation on 09/22/21 related to narcotic administration documentation.

Inspection Report

Complaint Investigation
Deficiencies: 2 Date: 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.

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.
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.

Deficiencies (2)
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
NameTitleContext
Julie TroyWellness DirectorSigned the Plan of Correction response letter.
Loan NguyenSupervising Nurse ConsultantRecipient of the violation letter and Plan of Correction.

Inspection Report

Plan of Correction
Deficiencies: 2 Date: 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 the Regulations of Connecticut State Agencies and/or General Statutes 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.

Deficiencies (2)
Failure to ensure the development of comprehensive safety measures to prevent elopement by a client who eloped for six hours and exhibited exit seeking behaviors.
Failure of Assisted Living Services Agency nurses and supervisors to follow policies, provide oversight and education, and complete a comprehensive investigation of narcotic discrepancies.
Report Facts
Visit dates: January 22, 24 and February 6, 2020 Duration of elopement: 6 Date of admission for Client #1: 10/27/19 Date of admission for Client #2: 6/28/19 Date of narcotic discrepancy incident: 1/5/2020 Missing liquid morphine: 9 Missing liquid Ativan: 7 Date of plan of correction completion: Door alarm education completed 2/14/20, policy completed 3/1/20

Employees mentioned
NameTitleContext
Loan NguyenSupervising Nurse ConsultantAuthor of the initial violation letter and recipient of the plan of correction response
Julie TroyWellness DirectorSigned the plan of correction response letter

Inspection Report

Plan of Correction
Deficiencies: 1 Date: 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)
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
NameTitleContext
Loan NguyenSupervising Nurse ConsultantAuthor of the violation letter and investigation report
Julie TroySupervisor of Assisted Living Services Agency / Wellness DirectorRecipient of the violation letter and author of the plan of correction

Viewing

Loading inspection reports...