Inspection Report Summary
The most recent inspection on June 20, 2024, identified deficiencies related to failure to follow the Missing Resident Response policy and supervision of assisted living services. Earlier inspections showed mostly clean results, with one substantiated complaint investigation in late 2021 involving a failure to update a client’s service plan after a change in condition. The main issues across reports involved client safety protocols and timely updating of service plans. Complaint investigations were generally unsubstantiated except for the 2021 case related to client care documentation. The recent findings suggest some ongoing challenges with policy adherence, following a period of compliance in prior years.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
0.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
86% better than Connecticut average
Connecticut average: 5.6 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
76 residents
Based on a March 2023 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Renewal
Deficiencies: 0
Jun 20, 2024
Visit Reason
The inspection was conducted as a renewal licensing inspection of The Residence at Westport, an Assisted Living Service Agency (ALSA).
Findings
Violations of the General Statutes of Connecticut and/or regulations of Connecticut State Agencies were identified at the time of this inspection. Further details are referenced in an attached violation letter.
Report Facts
License Number: 223
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Megan Edson-Sawyer | Nurse Consultant, Survey Team Leader | Signature of FLIS Staff and Survey Team Leader for the inspection |
| Elizabeth Heiney | Supervisor | Supervisor for the inspection |
Inspection Report
Renewal
Deficiencies: 0
Jun 20, 2024
Visit Reason
The inspection was conducted as a licensing renewal inspection for The Residence at Westport.
Findings
Violations of the General Statutes of Connecticut and/or regulations of Connecticut State Agencies were identified at the time of this inspection, with an attached violation letter dated 07/15/2024.
Report Facts
License Number: 223
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Megan Edson-Sawyer | Survey Team Leader | Named as Survey Team Leader and report submitter |
| Elizabeth Heiney | Supervisor | Named as Supervisor |
Inspection Report
Renewal
Deficiencies: 1
Jun 20, 2024
Visit Reason
The inspection visit was an unannounced licensure renewal inspection conducted by the Department of Public Health on June 20, 2024, to assess compliance with state regulations at The Residence at Westport.
Findings
The inspection identified violations related to failure to follow the Missing Resident Response policy, which compromised client safety. Specifically, the Assisted Living Services Agency (ALSA) did not properly respond to an elopement incident involving a client in the secured memory care unit.
Deficiencies (1)
| Description |
|---|
| Failure to follow the Missing Resident Response policy to ensure client safety, including not immediately searching the stairwell and adjacent areas after a door alarm was activated. |
Report Facts
Date of visit: Jun 20, 2024
Number of corrective action dates: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nicole Ashby | Resident Care Director | Named as responsible staff member ensuring compliance with plan of correction |
| Addie Ricci | Executive Director | Named as responsible staff member ensuring compliance with plan of correction and recipient of violation letter |
| Deanna Dunning | Reflections Director | Named as responsible staff member ensuring compliance with plan of correction |
| Elizabeth Heiney | Supervising Nurse Consultant | Author of violation letter and contact for response |
Inspection Report
Plan of Correction
Deficiencies: 1
Jun 20, 2024
Visit Reason
The document is a plan of correction submitted in response to an unannounced licensure renewal inspection conducted on June 20, 2024, by the Connecticut Department of Public Health.
Findings
The department found violations related to the supervision of assisted living services and failure to follow the Missing Resident Response policy to ensure client safety.
Deficiencies (1)
| Description |
|---|
| Violation of Regulations of Connecticut State Agencies Section 19-13-D105 (g) Supervisor of assisted living services (2)(A)(B) and/or (h) Nursing Services provided by an assisted living services agency (J) (vi) and/or (i) Assisted living aide services provided by an assisted living services agency (5)(B). |
Report Facts
Dates of corrective actions: Corrective actions and re-education completed on 4/18/2024, 4/25/2024, 5/22/2024 and monthly for the next 6 months.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nicole Ashby | Resident Care Director | Named as staff responsible for ensuring the institution's compliance. |
| Addie Ricci | Executive Director | Named as staff responsible for ensuring the institution's compliance and signed the plan of correction. |
| Deanna Dunning | Reflections Director | Named as staff responsible for ensuring the institution's compliance. |
Inspection Report
Complaint Investigation
Census: 76
Deficiencies: 0
Mar 30, 2023
Visit Reason
The inspection visit was conducted as a complaint investigation related to complaint #CT# 34259.
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 or programs and Part Time Infection Prevention and Control Specialist requirements were completed.
Complaint Details
Complaint #CT# 34259 was investigated and found to have no substantiated violations at the time of inspection.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michael J. Smith | RN Nurse Consultant | Report submitted by Michael J. Smith, RN. |
| Hanithah Manickam | Ex. Director | Personnel contacted during inspection. |
| Missy Stenqvist | RN, SALSA | Personnel contacted during inspection. |
Inspection Report
Renewal
Census: 96
Deficiencies: 0
Jun 16, 2022
Visit Reason
The inspection was a re-licensure visit and renewal inspection to review government authority, quality assurance, client records, personnel files, and other compliance areas.
Findings
No violations of the General Statutes of Connecticut or regulations were identified at the time of this inspection. Verification of Alzheimer's special care units and infection prevention requirements were confirmed.
Report Facts
Staff count: 60
Memory clients: 7
ALSA clients: 26
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michael J. Smith | Nurse Consultant | Report submitted by and signature on inspection report |
| Hanithah Manickam | Ex Director | Personnel contacted during inspection |
| Kim Russo | RN, SALSA | Personnel contacted during inspection |
Inspection Report
Plan of Correction
Deficiencies: 1
Dec 21, 2021
Visit Reason
Unannounced visits were made to The Residence At Westport on December 21, 22 and 27, 2021 by representatives of the Facility Licensing and Investigations Section of the Department of Public Health for the purpose of conducting an investigation.
Findings
The investigation found that the Assisted Living Agency Services (ALSA) failed to update Client #1's service program with a change in condition after an alleged sexual encounter and behavioral changes. The facility did not update the service plan to reflect changes in the client's behavior and failed to implement the policy for change of client status in a timely manner.
Complaint Details
The visit was complaint-related based on an allegation by Client #1 of a sexual encounter with Physical Therapist #1 on 12/14/21, and a history of hypersexual behavior toward male clients was noted. The complaint was investigated through clinical record reviews, staff interviews, and agency documentation.
Deficiencies (1)
| Description |
|---|
| ALSA failed to update Client #1's Service Program with a change in condition after an alleged sexual encounter and behavioral changes. |
Report Facts
Dates of visits: 3
Audit percentage: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kim Russo | Supervisor of Assisted Living | Named in relation to the plan of correction and investigation |
| Cheryl Davis | Public Health Services Manager | Author of the violation letter and investigation |
| Hanithah Manickam | Executive Director | Named as responsible for ensuring compliance with the plan of correction |
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