Inspection Report Summary
The most recent inspection on December 17, 2024 identified a deficiency related to delayed staff response times to emergency call system alerts for one client. Earlier inspections showed a pattern of various deficiencies including nursing care issues such as failure to properly manage anticoagulant medication, incomplete client service plans, inadequate wound care, and documentation problems. Prior reports also noted communication and billing notification deficiencies, as well as a failure to report and investigate an abuse allegation. Complaint investigations were mostly substantiated when deficiencies were found, but fines, immediate jeopardy findings, or license actions were not listed in the available reports. The inspection history shows some recurring themes in nursing supervision and client care, with no clear trend of consistent improvement or worsening over time.
Deficiencies (last 8 years)
Deficiencies (over 8 years)
2.9 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
48% better than Connecticut average
Connecticut average: 5.6 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
80 residents
Based on a June 2023 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Dec 17, 2024
Visit Reason
An unannounced visit was made to Brighton Gardens Of Stamford Alsa on December 17, 2024 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 CT #40048.
Complaint Details
Complaint CT #40048 triggered the investigation. The complaint involved delayed staff response times to emergency calls for assistance. Substantiation status is not explicitly stated.
Findings
The agency staff failed to respond in a timely manner to emergency call system alerts for one client, with response times ranging from 11 to 24 minutes and failure to identify supervision of staff in timely response to an emergency pendant call.
Deficiencies (1)
Failure to respond in a timely manner to calls for assistance from the emergency call system for one client, with response times ranging from 11 to 24 minutes and failure to identify supervision of agency staff in timely response.
Report Facts
Response time in minutes: 11
Response time in minutes: 12
Response time in minutes: 24
Date of client move-in: Jan 25, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Elizabeth T. Heiney | Supervising Nurse Consultant | Author of the letter and contact for response regarding the investigation |
| Melissa Boyle | Executive Director | Facility Executive Director addressed in the letter and signer of the Plan of Correction |
Inspection Report
Renewal
Census: 80
Deficiencies: 0
Date: Jun 23, 2023
Visit Reason
The inspection was conducted as a licensing renewal inspection for the Assisted Living Services Agency (ALSA) at Brighton Gardens of Stamford Sunrise.
Complaint Details
The inspection included a complaint investigation with complaint number 34561, but no violations were found related to the complaint.
Findings
No violations of the General Statutes of Connecticut and/or regulations of Connecticut State Agencies were identified at the time of this inspection.
Report Facts
Memory care census: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Michael J. Smith | Nurse Consultant | Signature of FLIS Staff and report submitter |
| AJ Caporino | Ex Director | Personnel contacted during inspection |
| Mary Kay Polacek | SALSA | Personnel contacted during inspection |
Inspection Report
Renewal
Census: 114
Capacity: 114
Deficiencies: 0
Date: Jun 28, 2022
Visit Reason
The inspection was conducted as a licensing inspection and renewal of the facility license.
Findings
No 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 requirements were confirmed.
Report Facts
Memory Clients: 24
ALSA Clients: 90
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Michael J. Smith | RN Nurse Consultant | Report submitted by and signature on inspection report |
| AJ Caporino | Ex Director | Personnel contacted during inspection |
| Mary Kay Polacek | RN, SALSA | Personnel contacted during inspection |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jul 28, 2020
Visit Reason
An unannounced visit was made to Brighton Gardens Of Stamford Alsa on July 28, 2020 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 investigation identified a violation related to the failure of the Supervisor of Assisted Living Services Agency (SALSA) to ensure a client who sustained an unwitnessed fall received an assessment from the ALSA Registered Nurse. The client later expired after complications from the fall.
Deficiencies (1)
Failure to ensure the client received an assessment from the Assisted Living Services Agency (ALSA) Registered Nurse after an unwitnessed fall.
Report Facts
Inspection date: Jul 28, 2020
Plan of correction target date: Oct 9, 2020
Client expiration date: Jul 16, 2020
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Loan Nguyen | Supervising Nurse Consultant | Signed the notice of violation and correspondence |
| Mary Kay Polacek | Supervisor of Assisted Living Services Agency | Named in relation to the violation and plan of correction |
Inspection Report
Complaint Investigation
Deficiencies: 6
Date: Jun 19, 2019
Visit Reason
Unannounced visits were made to Brighton Gardens Of Stamford Alsa on June 19, 20 and 24, 2019 for the purpose of conducting multiple investigations related to complaint investigation numbers 25047 and 25325.
Complaint Details
Complaint investigation numbers 25047 and 25325 were the basis for the unannounced visits and findings.
Findings
The assisted living services agency failed to ensure the nursing administration of anticoagulant medication for one client over a period of eight months, including failure to obtain necessary bloodwork orders and inadequate nursing supervision and communication. Violations of Connecticut State regulations were identified and a plan of correction was required.
Deficiencies (6)
Failure to ensure nursing administration of needed anticoagulant for a period of eight months for one client with persistent atrial fibrillation.
Failure to obtain PT or INR bloodwork orders as routinely ordered and failure to address this with the physician.
Failure to identify nursing follow-up on obtaining physician’s orders for bloodwork and ensuring bloodwork was drawn and results communicated.
Failure of Licensed Practical Nurse (LPN) to follow through with Coumadin orders and communicate with other nurses to ensure continuity and safety of care.
Failure of nursing supervision and education provided to nursing staff prior to the incident to ensure continuity and safety of nursing care.
Failure to identify policies and procedures to direct nursing process of receiving physician’s orders for Coumadin and ensuring concurrent orders for PT and INR were obtained and followed up.
Report Facts
Inspection dates: 3
Plan of correction submission deadline: Nov 2, 2019
Client admission date: Jul 13, 2017
Medication administration period: 8
Medication dosage: 1
Medication dosage: 125
Plan of correction target date: Dec 30, 2019
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Kay Polacek | Supervisor of Assisted Living Services Agency | Named as personnel contacted during inspection |
| Michael J. Smith | Report submitted by | |
| Loan Nguyen | Supervising Nurse Consultant | Signed violation letter and approval for issuance of license |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jun 19, 2019
Visit Reason
Unannounced visits were made to Brighton Gardens Of Stamford Alsa on June 19, 20 and 24, 2019 by a representative of the Facility Licensing and Investigations Section of the Department of Public Health for the purpose of conducting multiple investigations.
Findings
Violations of the Regulations of Connecticut State Agencies and/or General Statutes were identified related to the failure to ensure proper nursing administration of anticoagulant medication for a client with persistent atrial fibrillation over an eight-month period, including lack of appropriate physician orders, nursing supervision, and follow-up on bloodwork results.
Deficiencies (1)
Failure to ensure the nursing administration of the needed anticoagulant for a period of eight months for one client with persistent atrial fibrillation, including lack of PT and INR orders, failure to follow up on bloodwork, and inadequate nursing supervision and education.
Report Facts
Inspection visit dates: 3
Plan of correction submission deadline: Nov 2, 2019
Medication dosage: 1
Medication dosage: 125
Plan of correction target date: Dec 30, 2019
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Loan Nguyen | Supervising Nurse Consultant | Signed the notice letter regarding violations and plan of correction |
| Mary Kay Polacek | Supervisor of Assisted Living Services Agency | Recipient of the letter and signer of the plan of correction |
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Dec 12, 2018
Visit Reason
Unannounced visits were made to Brighton Gardens Of Stamford ALSA on May 8, 9, 10, 2018 and December 12, 2018 by the Department of Public Health for the purpose of conducting multiple investigations related to compliance with Connecticut state regulations for assisted living services.
Complaint Details
The visit was complaint-related, triggered by allegations of noncompliance with state regulations regarding client care, documentation, and medication administration. The report details substantiated findings of multiple violations.
Findings
The investigation identified multiple violations including failure to update client service plans after falls, inadequate wound care and documentation, incomplete service plans by registered nurses, interference with the survey process by the Supervisor of Assisted Living Services Agency (SALSA), and unsafe medication administration practices leading to a client overdose. Deficiencies were found in documentation, staff training, and policy adherence.
Deficiencies (5)
Failure to update client service plan after falls and lack of interventions to prevent further falls.
Inadequate wound care services and inconsistent documentation regarding pressure ulcers and pilonidal cysts.
Failure of registered nurse to complete client service plans in compliance with state regulations.
Supervisor of Assisted Living Services Agency interfered with survey process by accessing surveyor's confidential folder without authorization.
Unsafe medication administration practices including failure to properly remove transdermal patches, inaccurate nursing documentation, and lack of staff orientation and supervision.
Report Facts
Dates of visits: May 8, 9, 10, 2018 and December 12, 2018
Number of Exelon patches found on client: 3
Measurements of coccyx wound: 3.3
Dates of client deaths: Client #1 expired on 9/30/17; Client #2 expired on 1/29/18
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Loan Nguyen | Supervising Nurse Consultant | Signed report and involved in investigation |
| Mary Kay Polacek | Supervisor of Assisted Living Services Agency | Named in report and responsible for plan of correction |
| LPN #11 | Licensed Practical Nurse | Involved in medication administration errors and failure to properly remove medication patches |
| LPN #12 | Licensed Practical Nurse | Had a pattern of medication errors; subject of performance and counseling improvement plans |
| LPN #13 | Licensed Practical Nurse | Involved in medication administration and patch application/removal |
| RN #1 | Registered Nurse | Completed wound care assessments without wound care certification; failed to update service plans |
| ALSA Aide #1 | Found client after fall but failed to document previous safety check times | |
| ALSA Aide #2 | Documented care but unable to document safety check times due to system limitations |
Inspection Report
Renewal
Deficiencies: 5
Date: Dec 12, 2018
Visit Reason
Unannounced visits were made to Brighton Gardens Of Stamford ALSA on May 8, 9, 10, 2018 and December 12, 2018 by a representative of the Facility Licensing and Investigations Section for the purpose of conducting multiple investigations, including complaint investigations #24509, 22793, and 23038.
Complaint Details
The visit included complaint investigations #24509, 22793, and 23038. Violations were substantiated as violations of Connecticut General Statutes and regulations were identified during the inspection.
Findings
Violations of the General Statutes of Connecticut and regulations of Connecticut State Agencies were identified, including failure to update client service plans after falls, failure to provide necessary wound care, failure to complete service plans, interference with survey process, and failure to ensure safe medication administration. A plan of correction was required to be submitted by January 21, 2019.
Deficiencies (5)
Agency failed to update client #1's service plan after a fall, including interventions to prevent further falls and updates to aide instruction sheets.
ALSA nurses failed to provide necessary wound care for client #2, including failure to identify responsibility for dressing changes and inconsistent wound classification.
ALSA registered nurse failed to complete service plans for clients #1 and #2 residing in memory care unit.
Supervisor of Assisted Living Services Agency interfered with survey process by opening surveyor's folder without authorization and failing to provide unrestricted access to documents and client records.
Agency failed to ensure safe administration of medication for client #11, including inaccurate and incomplete medication administration records and failure to follow medication management policies.
Report Facts
Inspection dates: May 8, 9, 10, 2018 and December 12, 2018
Plan of correction submission deadline: January 21, 2019
Client #1 admission date: 06/06/17
Client #2 admission date: 09/09/17
Client #11 admission date: 05/12/18
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Kay Polacek | Supervisor of Assisted Living Services Agency | Named as personnel contacted and involved in findings related to survey process interference and plan of correction. |
| Loan Nguyen | Supervising Nurse Consultant | Named as supervisor approving issuance of license and author of enforcement correspondence. |
Inspection Report
Complaint Investigation
Capacity: 120
Deficiencies: 0
Date: Jul 13, 2017
Visit Reason
The inspection was conducted as a complaint investigation related to complaint numbers #21930 and #21136.
Complaint Details
Complaint investigation numbers #21930 and #21136 were the basis for this inspection. Violations were substantiated as violations were identified during the inspection.
Findings
Violations of the General Statutes of Connecticut and/or regulations of Connecticut State Agencies were identified at the time of this inspection.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Kay Polacek | NA/UA | Personnel contacted during the inspection. |
| Michael T. Smith | Report submitted by. | |
| Logan D. Nguyen | Supervisor | Approval for issuance of license granted by. |
Inspection Report
Complaint Investigation
Capacity: 120
Deficiencies: 2
Date: Jul 13, 2017
Visit Reason
The inspection was conducted as a complaint investigation triggered by complaint investigation numbers #21930 and #21136, to assess violations of Connecticut State regulations at Brighton Gardens of Stamford ALSA.
Complaint Details
Complaint investigation numbers #21930 and #21136 were the basis for the visit. Violations were substantiated as indicated by the attached violation letter dated 2018-01-29.
Findings
The inspection found violations related to failure to notify the responsible party of changes in charges and billing at least 15 days prior to implementation, and failure to ensure the responsible party reviewed updated plans of care. Documentation and interviews revealed deficiencies in communication and record-keeping regarding client service programs and billing changes.
Deficiencies (2)
Failure to notify Client #1's Responsible Party of changes in charges and billing no less than 15 days prior to implementing the changes.
Failure to ensure the responsible party reviewed updated plans of care for Client #1.
Report Facts
Licensed bed capacity: 120
Complaint investigation numbers: 2
Billing increase amount: 25
Date of inspection: Jul 13, 2017
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Kay Polacek | Supervisor of Assisted Living Services Agency | Personnel contacted during inspection and named in report correspondence. |
| Loan Nguyen | Supervising Nurse Consultant | Named as the approving supervisor and author of violation letter. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jun 3, 2016
Visit Reason
An unannounced visit was made to Brighton Gardens Of Stamford Alsa on June 3, 2016, by a representative of the Facility Licensing and Investigations Section of the Department of Public Health for the purpose of conducting a complaint investigation (Complaint Investigation #20089).
Complaint Details
Complaint Investigation #20089 involved an allegation that Client #1 was slapped on the mouth by assisted living aides on 5/16/16, which was not properly reported or investigated. The SALSA supervisor received an email complaint on 5/17/16. The investigation found failure in reporting and investigation by aides and SALSA staff, but assessments indicated the client was free of bruising, redness, or pain at the alleged site.
Findings
The investigation found that the assisted living aides failed to report an allegation of abuse and the Supervisor of Assisted Living Services Agency (SALSA) failed to promptly and thoroughly investigate the allegation. Additionally, the agency failed to ensure accurate documentation of care and services provided to one client with specific needs.
Deficiencies (2)
Failure to report an allegation of abuse and failure to promptly and thoroughly investigate the allegation.
Failure to ensure accurate documentation of care and services provided to a client with specific needs.
Report Facts
Date of onsite inspection: Jun 3, 2016
Date additional information obtained: Jun 16, 2016
Complaint Investigation Number: 20089
Plan of Correction Submission Date: Aug 5, 2016
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Kay Polacek | Supervisor of Assisted Living Services Agency | Named in relation to the complaint investigation and plan of correction |
| Loan Nguyen | Supervising Nurse Consultant | Signed report and letter regarding inspection and violations |
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