Inspection Reports for Brookdale South Windsor

1715 Ellington Road,South Windsor, CT, CT

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Inspection Report Summary

The most recent inspection on June 7, 2024, found no deficiencies at Brookdale South Windsor. Earlier inspections also showed no violations, indicating a consistent compliance with state regulations in recent years. Prior reports from 2017 noted several deficiencies related to supervisory notification, care planning, complaint documentation, aide scope of practice, personnel files, and quality assurance processes. A complaint investigation at that time was substantiated concerning failure to document complaint resolution. The facility’s record shows improvement over time, with no deficiencies identified in the latest inspections.

Deficiencies (last 3 years)

Deficiencies (over 3 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

8 6 4 2 0
2017
2022
2024

Census

Latest occupancy rate 50 residents

Based on a August 2022 inspection.

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

Census over time

40 50 60 70 80 90 Jun 2017 Aug 2022
Inspection Report Renewal Deficiencies: 0 Jun 7, 2024
Visit Reason
The inspection was conducted as a licensing inspection with a renewal purpose for the facility Brookdale South Windsor.
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
License Number: 100
Employees Mentioned
NameTitleContext
David StevensExecutive DirectorPersonnel contacted during inspection
Stacey BabcockSALSAPersonnel contacted during inspection
Megan Edson-SawyerNurse Consultant and Survey Team LeaderSignature of FLIS Staff and report submitter
Elizabeth HeineySupervisorSupervisor of survey team
Inspection Report Renewal Capacity: 100 Deficiencies: 0 Jun 7, 2024
Visit Reason
The inspection was conducted as a licensing inspection for renewal purposes at the Brookdale South Windsor assisted living facility.
Findings
No violations of the General Statutes of Connecticut or regulations of Connecticut State Agencies were identified at the time of this inspection. Approval for issuance of license was granted.
Employees Mentioned
NameTitleContext
David StevensExecutive DirectorPersonnel contacted during the inspection
Stacey BabcockSALSAPersonnel contacted during the inspection
Megan Edson-SawyerNurse ConsultantSurvey Team Leader and report submitter
Elizabeth HeineySupervisorSupervisor of the survey team
Inspection Report Renewal Census: 50 Deficiencies: 0 Aug 22, 2022
Visit Reason
The inspection was conducted as a renewal licensing inspection for Brokdale South Windsor.
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 and infection prevention requirements were completed.
Report Facts
Memory Care/Traditional census: 19
Employees Mentioned
NameTitleContext
David StevensExecutive DirectorPersonnel contacted during inspection
Stacey BabcockSALSAPersonnel contacted during inspection
Megan Edson-SawyerNurse ConsultantSignature of FLIS Staff and report submitter
Inspection Report Renewal Census: 50 Deficiencies: 0 Aug 22, 2022
Visit Reason
The inspection was a licensing inspection conducted as a renewal of the facility's license.
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 and full-time infection prevention and control specialist requirements were confirmed.
Report Facts
Memory Care/Traditional beds: 19
Employees Mentioned
NameTitleContext
David StevensExecutive DirectorPersonnel contacted during the inspection
Stacey BabcockSALSAPersonnel contacted during the inspection
Megan Edson-SawyerReport submitted by
Inspection Report Renewal Census: 77 Capacity: 80 Deficiencies: 6 Jun 29, 2017
Visit Reason
The inspection was conducted as a renewal/licensing inspection with unannounced visits made on July 14, 15, 18, and 19, 2016 by the Department of Public Health to Brookdale South Windsor for the purpose of conducting a relicensing inspection.
Findings
The Assisted Living Services Agency (ALSA) was found to have multiple violations including failure to notify the Department of Public Health of the absence of the supervisor for more than one month, failure to assess and update plans of care, failure to document complaint investigations, provision of care outside the aide scope of practice, and deficiencies in personnel files and quality assurance programs. Corrective actions and re-education plans were outlined with completion dates.
Complaint Details
The complaint investigation was related to failure to document the investigation and/or resolution of a complaint for one client (#4).
Deficiencies (6)
Description
Failure to notify the Department of Public Health of the absence of the supervisor of assisted living services agency (SALSA) for longer than one month.
Failure to assess and/or update the plan of care and/or coordinate services with client and/or family for multiple clients.
Failure to document the investigation and/or resolution of a complaint for one client.
Provision of care outside the aide scope of practice by an agency aide.
Personnel files failed to meet requirements including missing job descriptions, annual evaluations, physical examinations, TB testing, and competency evaluations.
Failure to ensure completion of timely Quality Assurance (QA) meetings and annual QA reports for 2014 and 2015.
Report Facts
Number of onsite inspection dates: 4 Licensed bed capacity: 80 Census: 77 Number of home visits: 2 Number of records reviewed: 5
Employees Mentioned
NameTitleContext
Loan NguyenSupervising Nurse ConsultantReport submitted by and approval for issuance of license granted by
Christine WaldieSupervisor of Assisted Living Services AgencyNamed as personnel contacted and recipient of the inspection letter
Cathy PisarzExecutive DirectorNamed as personnel contacted and Service Coordinator
Adrienne PerryRN, Acting SALSANamed as personnel contacted and SALSA
Linda L'HeureuxRN, SALSA DesigneeNamed as personnel contacted and SALSA Designee

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