The most recent inspection on August 7, 2024, found no deficiencies and the related complaint was not substantiated. Earlier inspections showed a mixed record, with prior reports noting deficiencies in client care oversight, emergency response, and documentation during complaint investigations in 2023, and issues related to medication management, staffing, and food service in 2017. Inspectors cited failures to follow physician orders, complete incident reports, and maintain proper documentation as main themes of deficiencies. Complaint investigations were mostly unsubstantiated except for substantiated violations in 2017 and 2023 related to client rights and care procedures. The facility’s inspection history indicates improvement over time, with the most recent visit showing compliance after earlier concerns.
Deficiencies (last 5 years)
Deficiencies (over 5 years)2.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
54% better than Connecticut average
Connecticut average: 5.6 deficiencies/year
Deficiencies per year
129630
2017
2018
2022
2023
2024
Census
Latest occupancy rate100% occupied
Based on a May 2022 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
The inspection visit was conducted as a complaint investigation related to CT#40367.
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 part-time Infection Prevention and Control Specialist requirements were also confirmed.
Complaint Details
Complaint investigation related to CT#40367; no violations were found and the complaint was not substantiated.
Unannounced visits were made to Brightview On New Canaan on March 21, 2023, by a representative of the Facility Licensing and Investigations Section of the Department of Public Health for the purpose of conducting a Complaint Investigation Survey, plus Verification of Alzheimer's Special Care Units, Full Time Infection Prevention and Control Specialist, and other requirements of P.A. 21-185.
Findings
The Assisted Living Services Agency failed to review the Client service plan as required, ensure oversight of nursing care, follow physician orders, agency policies, and procedures, and failed to ensure a Client's rights. Specific findings included failure to locate a Client's DNR/Advanced Directive form, failure to initiate CPR appropriately, failure to follow emergency and advanced care planning policies, and failure to complete required incident reports.
Complaint Details
Complaint #34171 triggered the investigation. The complaint involved failure to follow proper procedures related to a Client's DNR status, emergency response, and documentation. The report does not explicitly state substantiation status.
Deficiencies (4)
Description
Failure to review Client service plan at required intervals and ensure oversight of nursing care and adherence to physician orders and agency policies.
Failure to locate Client's DNR/Advanced Directive form and failure to initiate or stop CPR according to directives.
Failure to follow Client Emergency Response/Change in Condition policy and Advanced Care Planning policy.
Failure to complete incident report and investigate in accordance with agency policies after Client's death.
Report Facts
Clients in survey sample: 3Client service plan review interval: 120Client #1 admission date: Aug 21, 2019Client #1 120-day assessment date: Nov 21, 2022Client #1 service plan date: Jul 4, 2022Client #1 death date: Mar 9, 2023
Employees Mentioned
Name
Title
Context
Elizabeth Heiney
Supervising Nurse Consultant
Named as contact for response and instructions in the complaint investigation
Kathleen Lane
Executive Director
Named as responsible staff member for ensuring compliance with Plan of Correction
The inspection visit was conducted as a complaint investigation related to complaint CT#34171 and to verify violations of the General Statutes of Connecticut and/or regulations of Connecticut State Agencies.
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 and full-time Infection Prevention and Control Specialist requirements were also confirmed.
Complaint Details
Complaint investigation CT#34171 was conducted and violations were identified.
The inspection was a renewal licensing inspection for Brightview on New Canaan ALSA facility.
Findings
No violations of the General Statutes of Connecticut or regulations of Connecticut State Agencies were identified at the time of this inspection. Verification of Alzheimer's special care units or programs and full-time Infection Prevention and Control Specialist requirements were confirmed.
The inspection visit was conducted as a licensing inspection and renewal of the facility's license, including verification of Alzheimer's special care units and infection prevention requirements.
Findings
The report indicates approval for issuance of the license following the inspection. No violations or citations are noted in the provided pages.
The inspection was conducted as a renewal visit with a complaint investigation related to violations of Connecticut State Agencies regulations.
Findings
Violations of the General Statutes of Connecticut and regulations were identified, including failures in medication management, documentation, staffing, and client service records. A violation letter dated May 29, 2018, was attached detailing these findings.
Complaint Details
Complaint investigation #21612 was conducted. Violations were substantiated as indicated by the attached violation letter dated May 29, 2018.
Deficiencies (9)
Description
Failure to maintain accurate and authentic documentation of medication administration, coordination of care, and assistance with meals for three clients requiring medication management.
Failure to appoint a registered nurse to serve as RN designee in the absence of the Supervisor of Assisted Living Services Agency.
Failure to implement proper hand hygiene practices by staff prior to removing and applying medication patches.
Failure to document controlled substance counts by two nurses every shift in accordance with agency policy.
Failure to ensure medication administration records were accurately signed and documented by nursing staff and aides.
Failure to identify documentation of coordination of care with clients or responsible parties.
Failure to ensure ALSA aides wore hair nets while handling food and to follow safe food handling procedures.
Failure to include serving food as a job requirement for ALSA aides, despite expectations for food service assistance.
Failure to maintain adequate staffing and supervision by a registered nurse designee.
Report Facts
Licensed Bed Capacity: 99Census: 81Inspection Dates: Inspection visits occurred on 2017-09-08 and 2017-09-19.
Employees Mentioned
Name
Title
Context
Gehann Daniel
Supervisor of Assisted Living Services Agency / Health Service Director/SALSA
Named in relation to the inspection and findings, including medication management and staffing.
Loan D. Nguyen
Supervising Nurse Consultant
Supervisor who approved issuance of license and signed related correspondence.
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