Inspection Reports for
The Residence at Westport

CT, 06880

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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/year

Deficiencies per year

4 3 2 1 0
2021
2022
2023
2024

Census

Latest occupancy rate 76 residents

Based on a March 2023 inspection.

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

Occupancy over time

64 72 80 88 96 104 Jun 2022 Mar 2023

Inspection Report

Renewal
Deficiencies: 0 Date: 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
NameTitleContext
Megan Edson-SawyerNurse Consultant, Survey Team LeaderSignature of FLIS Staff and Survey Team Leader for the inspection
Elizabeth HeineySupervisorSupervisor for the inspection

Inspection Report

Renewal
Deficiencies: 0 Date: 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
NameTitleContext
Megan Edson-SawyerSurvey Team LeaderNamed as Survey Team Leader and report submitter
Elizabeth HeineySupervisorNamed as Supervisor

Inspection Report

Renewal
Deficiencies: 1 Date: 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)
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
NameTitleContext
Nicole AshbyResident Care DirectorNamed as responsible staff member ensuring compliance with plan of correction
Addie RicciExecutive DirectorNamed as responsible staff member ensuring compliance with plan of correction and recipient of violation letter
Deanna DunningReflections DirectorNamed as responsible staff member ensuring compliance with plan of correction
Elizabeth HeineySupervising Nurse ConsultantAuthor of violation letter and contact for response

Inspection Report

Plan of Correction
Deficiencies: 1 Date: 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)
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
NameTitleContext
Nicole AshbyResident Care DirectorNamed as staff responsible for ensuring the institution's compliance.
Addie RicciExecutive DirectorNamed as staff responsible for ensuring the institution's compliance and signed the plan of correction.
Deanna DunningReflections DirectorNamed as staff responsible for ensuring the institution's compliance.

Inspection Report

Complaint Investigation
Census: 76 Deficiencies: 0 Date: Mar 30, 2023

Visit Reason
The inspection visit was conducted in response to complaint number CT# 34259 to investigate alleged violations at The Residence at Westport ALSA.

Complaint Details
Complaint investigation related to complaint number CT# 34259. The complaint was not substantiated as no violations were found during the inspection.
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.

Employees mentioned
NameTitleContext
Michael J. SmithRN Nurse ConsultantNamed as the report submitter and nurse consultant conducting the inspection.
Hanithah ManickamEx. DirectorPersonnel contacted during the inspection.
Missy StenqvistRN, SALSAPersonnel contacted during the inspection.

Inspection Report

Renewal
Census: 96 Deficiencies: 0 Date: 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
NameTitleContext
Michael J. SmithNurse ConsultantReport submitted by and signature on inspection report
Hanithah ManickamEx DirectorPersonnel contacted during inspection
Kim RussoRN, SALSAPersonnel contacted during inspection

Inspection Report

Plan of Correction
Deficiencies: 1 Date: 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.

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.
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.

Deficiencies (1)
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
NameTitleContext
Kim RussoSupervisor of Assisted LivingNamed in relation to the plan of correction and investigation
Cheryl DavisPublic Health Services ManagerAuthor of the violation letter and investigation
Hanithah ManickamExecutive DirectorNamed as responsible for ensuring compliance with the plan of correction

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