Inspection Reports for Masonicare At Ashlar Village

74 Cheshire Rd, Wallingford, CT 06492, CT, 06492

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Inspection Report Summary

The most recent inspection on May 29, 2024, identified deficiencies related to violations of Connecticut statutes and regulations during a complaint investigation and re-licensure review. Earlier inspections showed a mixed pattern, with some complaint investigations substantiating violations and others finding no issues, while renewal inspections in 2022 were clean. The main themes of deficiencies involved regulatory compliance issues, including documentation and clinical record-keeping. Complaint investigations were substantiated at times, including concerns about clinical orders and family notification, but enforcement actions such as fines or license suspensions were not listed in the available reports. The inspection history shows ongoing challenges with compliance, with no clear trend of improvement or worsening over time.

Deficiencies (last 6 years)

Deficiencies (over 6 years) 0.7 deficiencies/year

Deficiencies are regulatory violations found during state inspections.

88% better than Connecticut average
Connecticut average: 5.6 deficiencies/year

Deficiencies per year

4 3 2 1 0
2016
2017
2018
2022
2023
2024

Census

Latest occupancy rate 93% occupied

Based on a February 2023 inspection.

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

Census over time

30 60 90 120 150 May 2016 Oct 2017 Feb 2023

Inspection Report

Complaint Investigation
Capacity: 89 Deficiencies: 0 Date: May 29, 2024

Visit Reason
The inspection was conducted as a complaint investigation related to Complaint #38793 and included a licensing inspection and renewal review.

Complaint Details
Inspection was triggered by Complaint #38793. Violations were substantiated as indicated by the attached violation letter dated 7/1/24.
Findings
Violations of the General Statutes of Connecticut and/or regulations of Connecticut State Agencies were identified during the inspection. A violation letter dated 7/1/24 was attached. The re-licensure survey included a tour and review of government authority minutes, quality assurance meeting minutes, personnel folders, and clinical record reviews.

Report Facts
Census: 123 Total Capacity: 89

Employees mentioned
NameTitleContext
Michael J. SmithNurse ConsultantSignature of FLIS staff and report submitter
Rachael LaudanoExDirectorPersonnel contacted during inspection

Inspection Report

Monitoring
Deficiencies: 0 Date: Jul 26, 2023

Visit Reason
The inspection visit was conducted as a strike monitoring supplement to the licensing inspection report.

Findings
The report does not provide detailed findings or deficiencies within the provided pages; it is a monitoring visit related to strike conditions.

Employees mentioned
NameTitleContext
Megan Edson-SawyerSurvey Team Leader and Nurse ConsultantReport submitter and survey team leader for the inspection.
Lauren DubuqueExecutive DirectorPersonnel contacted during the inspection.
Sarah PattersonRN DesigneePersonnel contacted during the inspection.
Elizabeth HeineySupervisorSupervisor for the survey team.

Inspection Report

Complaint Investigation
Census: 76 Capacity: 82 Deficiencies: 0 Date: Feb 1, 2023

Visit Reason
The inspection visit was conducted as a complaint investigation related to Complaint Investigation #33791.

Complaint Details
Complaint Investigation #33791 was the reason for the visit; 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.

Report Facts
Licensed Bed Capacity: 82 Census: 76

Employees mentioned
NameTitleContext
Lauren DubuqueEDPersonnel contacted during the inspection
Susan CartierSALSAPersonnel contacted during the inspection
Laura BoggioSurvey Team LeaderConducted the inspection
Elizabeth HeineySupervisorSupervised the inspection

Inspection Report

Complaint Investigation
Census: 76 Capacity: 82 Deficiencies: 0 Date: Feb 1, 2023

Visit Reason
The inspection visit was conducted as a complaint investigation related to complaint #33893.

Complaint Details
Complaint investigation #33893 was conducted and found no violations.
Findings
No violations of the General Statutes of Connecticut and/or regulations of Connecticut State Agencies were identified at the time of this inspection.

Inspection Report

Renewal
Deficiencies: 0 Date: Aug 22, 2022

Visit Reason
The inspection was conducted as a renewal licensing inspection for Masonicare Ashlar Village.

Findings
No violations of the General Statutes of Connecticut and/or regulations were identified at the time of this inspection.

Inspection Report

Renewal
Deficiencies: 0 Date: Aug 23, 2018

Visit Reason
The inspection was conducted as a renewal licensing inspection and included a complaint investigation (Complaint Investigation #23078).

Complaint Details
Complaint Investigation #23078 was part of this inspection; substantiation status is not stated.
Findings
Violations of the General Statutes of Connecticut and/or regulations were identified at the time of this inspection, as indicated by the attached violation letter.

Employees mentioned
NameTitleContext
Julie BaisleySAUAPersonnel contacted during the inspection.
Perry PhillipsEDPersonnel contacted during the inspection.

Inspection Report

Complaint Investigation
Census: 122 Deficiencies: 1 Date: Oct 3, 2017

Visit Reason
The inspection was conducted as a complaint investigation based on Complaint Investigation #20921 and #21416, involving unannounced visits on October 3, 4, and 5, 2017 to Masonicare At Ashlar Village / Pond Ridge.

Complaint Details
Complaint Investigation #20921 and #21416. Violations were identified and substantiated as noted in the attached violation letter dated 2018-07-23.
Findings
The investigation found that for one client requiring oxygen therapy, the agency failed to ensure a physician's order for the oxygen therapy was obtained. Specific deficiencies included lack of physician orders for oxygen and humidification equipment and incomplete documentation in the client's medical record.

Deficiencies (1)
Failure to ensure the physician ordered the oxygen therapy for Client #4 who required oxygen therapy.
Report Facts
Census: 122

Employees mentioned
NameTitleContext
Elizabeth BrownSupervisor of Assisted Living Services AgencyPersonnel contacted during inspection
Loan NguyenSupervising Nurse ConsultantReport submitted by and referenced in violation letter
Jason RiegerAssistant AdministratorSigned Plan of Correction

Inspection Report

Renewal
Census: 35 Capacity: 41 Deficiencies: 3 Date: May 23, 2016

Visit Reason
Unannounced visits were made on May 23 and 24, 2016 for the purpose of conducting an investigation and a licensing renewal survey at Masonicare At Ashlar Village / Pond Ridge Assisted Living.

Complaint Details
Complaint #18711 triggered the investigation. The complaint was substantiated as violations were identified during the inspection.
Findings
The inspection identified violations related to failure to notify family of clinical changes, inadequate updating of client service programs, and failure to maintain client safety in a memory impaired secured unit. Three violations were noted and a plan of correction was requested.

Deficiencies (3)
Nursing staff failed to notify a family member or significant other of a change in Client #1's condition in a timely manner.
Client service program was not updated to reflect new goals and interventions related to oral hygiene.
Assisted living agency failed to maintain the safety of a client who was a fall risk and experienced multiple falls.
Report Facts
Number of violations noted: 3 Census: 35 Licensed Capacity: 41

Employees mentioned
NameTitleContext
Loan NguyenSupervising Nurse ConsultantSigned the violation letter and approval for issuance of license.
Jason RiegerAssistant Administrator / Assisted LivingNamed in the Plan of Correction document.

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