Inspection Report Summary
The most recent inspection on July 22, 2025 identified deficiencies related to medication management and safety monitoring, specifically a failure to follow agency policies on signing off medications, and the complaint was substantiated. Earlier inspections showed a pattern of deficiencies involving client service plans, medication management, safety monitoring, and infection prevention requirements, with some complaint investigations finding violations while others were unsubstantiated. Prior reports noted issues with documentation, safety checks for clients at risk of falls, and incomplete nursing policies, but enforcement actions such as aide termination were limited to isolated incidents. Complaint investigations were mixed, with several unsubstantiated complaints and some substantiated violations primarily related to care documentation and safety procedures. The inspection history indicates ongoing challenges in medication and safety policy adherence, with no clear trend of overall improvement or worsening.
Deficiencies (last 6 years)
Deficiencies (over 6 years)
1.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
77% better than Connecticut average
Connecticut average: 5.6 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
134% occupied
Based on a May 2024 inspection.
Census over time
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jul 22, 2025
Visit Reason
An unannounced visit was made to Bal Windsor (Village at Buckland Court) on July 22, 2025 by a representative of the Facility Licensing and Investigations Section of the Department of Public Health for the purpose of conducting an investigation related to a complaint.
Complaint Details
Complaint #40874 triggered the investigation. The visit was complaint-related and involved a review of clinical records, agency policies, and staff interviews. The complaint was substantiated based on the findings.
Findings
The investigation found a violation of Connecticut State Regulations regarding assisted living services related to failure to follow agency policies on Code of Conduct, specifically medication management and safety monitoring for one client. The Assisted Living Services Agency/ALSA aide failed to sign off medications at the time they were handed to the client, violating agency procedures and Code of Conduct policies.
Deficiencies (1)
Failure to follow agency policies on Code of Conduct related to medication management and safety monitoring, including failure to sign off medications at the time they were handed to the client.
Report Facts
Medication dosage: 10
Dates: Jul 19, 2024
Dates: Aug 29, 2024
Dates: Aug 27, 2024
Dates: Jul 22, 2025
Dates: Sep 17, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Elizabeth T. Heiney | Supervising Nurse Consultant | Named as contact for plan of correction response and instructions |
| Allyson Sweeney | Executive Director | Named as recipient of violation letter and author of plan of correction response |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jul 22, 2025
Visit Reason
The inspection was conducted as a complaint investigation related to complaint numbers CT #41680 and #42785.
Complaint Details
Complaint investigation related to CT #41680 and #42785 with violations identified.
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 and full-time infection prevention and control specialist requirements were also confirmed.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Allyson Sweeney | ED | Personnel contacted during inspection |
| Kelly Switzer | SALSA | Personnel contacted during inspection |
| Karen Donato | RNC | Report submitted by |
Inspection Report
Complaint Investigation
Census: 103
Capacity: 77
Deficiencies: 0
Date: May 22, 2024
Visit Reason
The inspection visit was conducted as a complaint investigation related to CT#38827 & 38292.
Complaint Details
The visit was complaint-related with violations identified; specific substantiation status is not stated.
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 and part-time Infection Prevention and Control Specialist requirements were also conducted.
Report Facts
Census: 103
Total Capacity: 77
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Allyson Sweeney | Executive | Personnel contacted during inspection |
| Michael J. Smith | Nurse Consultant | Signature of FLIS Staff and report submitter |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: May 22, 2024
Visit Reason
The inspection was conducted as a complaint investigation related to complaint number 38378.
Complaint Details
Complaint investigation #38378 was conducted and found no violations; the complaint was not substantiated.
Findings
No violations of the General Statutes of Connecticut and/or regulations of Connecticut State Agencies were identified at the time of this inspection.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Elizabeth T. Heiney | SNC Nurse Consultant | Signature of FLIS Staff and report submitter |
| Allyson Sweeney | E.D. | Personnel contacted during inspection |
| Kelly Switzer | RN - SALSA | Personnel contacted during inspection and Part Time Infection Prevention and Control Specialist |
Inspection Report
Renewal
Census: 7
Capacity: 26
Deficiencies: 0
Date: Mar 14, 2024
Visit Reason
The inspection was conducted as a licensing inspection for renewal purposes and included review of complaint investigations numbered 37437, 37951, and 38149.
Complaint Details
Complaint investigations #37437, #37951, and #38149 were reviewed during this inspection.
Findings
Violations of the General Statutes of Connecticut and/or regulations of Connecticut State Agencies were identified at the time of this inspection, as referenced in an attached violation letter dated 3/19/24.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Allyson Sweeney | Executive Director | Personnel contacted during the inspection. |
| Kelly Switzer | SALSA | Personnel contacted during the inspection. |
| Megan Edson-Sawyer | Survey Team Leader | Report submitted by. |
| Elizabeth Heiney | Supervisor | Supervisor of the survey team. |
Inspection Report
Renewal
Census: 72
Deficiencies: 0
Date: Mar 14, 2024
Visit Reason
The inspection was conducted as a renewal licensing inspection, including review of complaint investigations numbered 37437, 37951, and 38149.
Findings
Violations of the General Statutes of Connecticut and/or regulations of Connecticut State Agencies were identified at the time of this inspection, as noted in an attached violation letter.
Report Facts
Complaint investigations referenced: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Allyson Sweeney | Executive Director | Personnel contacted during the inspection. |
| Kelly Switzer | SALSA | Personnel contacted during the inspection. |
| Megan Edson-Sawyer | Survey Team Leader | Report submitted by. |
| Elizabeth Heiney | Supervisor | Supervisor listed on the report. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jan 2, 2024
Visit Reason
The inspection was conducted as a complaint investigation related to Complaint CT #36922 and to verify violations of the General Statutes of Connecticut and/or regulations of Connecticut State Agencies.
Complaint Details
Complaint investigation CT #36922 was conducted and violations were substantiated as 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. Verification of Alzheimer's special care units or programs and full-time Infection Prevention and Control Specialist requirements were also confirmed.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Karen Donato | RNC | Report submitted by Karen Donato RNC |
| Allyson Sweeney | ED | Personnel contacted during inspection |
| Kelly Switzer | SALSA | Personnel contacted during inspection |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jan 2, 2024
Visit Reason
The inspection visit was conducted as a complaint investigation related to Complaint CT #36922 and to verify compliance with Alzheimer's special care unit requirements and infection prevention and control specialist mandates.
Complaint Details
Complaint Investigation CT #36922 was the basis for the visit. Violations were found and documented in an attached violation letter.
Findings
Violations of the General Statutes of Connecticut and/or regulations were identified during the inspection. The report references an attached violation letter and notes verification of Alzheimer's special care units and infection prevention requirements.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Allyson Sweeney | Executive Director | Personnel contacted during the inspection |
| Kelly Switzer | SALSA | Personnel contacted during the inspection |
| Karen Donato | Nurse Consultant | Report submitted by |
Inspection Report
Complaint Investigation
Census: 96
Deficiencies: 0
Date: Dec 20, 2022
Visit Reason
The inspection was conducted as a complaint investigation, specifically referenced as Complaint Investigation #33501.
Complaint Details
Complaint Investigation #33501 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.
Report Facts
Census: 96
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Allyson Sweeney | Executive Director | Personnel contacted during the inspection. |
| Kelly Switzer | RN SALSA | Personnel contacted during the inspection. |
Inspection Report
Complaint Investigation
Census: 96
Deficiencies: 0
Date: Dec 20, 2022
Visit Reason
The inspection visit was conducted as a complaint investigation related to Complaint Investigation #33501.
Complaint Details
Complaint Investigation #33501 was the reason for the visit; no violations were found.
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
Census: 96
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Allyson Sweeney | Executive Director | Personnel contacted during the inspection |
| Kelly Switzer | RN SALSA | Personnel contacted during the inspection |
Inspection Report
Complaint Investigation
Census: 96
Deficiencies: 0
Date: Dec 20, 2022
Visit Reason
The inspection visit was conducted as a complaint investigation identified by Complaint Investigation #33501.
Complaint Details
Complaint Investigation #33501 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.
Report Facts
Census: 96
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Allyson Sweeney | Executive Director | Personnel contacted during the inspection |
| Kelly Switzer | RN SALSA | Personnel contacted during the inspection |
Inspection Report
Renewal
Census: 81
Deficiencies: 0
Date: Aug 8, 2022
Visit Reason
The inspection was conducted as a renewal licensing inspection for The Village at Buckland Court (BAL 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. Verification of Alzheimer's special care units and infection prevention requirements were confirmed.
Report Facts
Memory Care/Traditional census: 18
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Peg Sullivan | Executive Director | Personnel contacted during inspection |
| Megan Edson-Sawyer | Nurse Consultant | Signature of FLIS Staff and report submitter |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Mar 3, 2022
Visit Reason
An unannounced visit was made to Bal Windsor on March 3, 2022 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.
Complaint Details
Complaint #31734 was investigated. The complaint involved issues with client service records, including incomplete service plans and missing documentation of aide care logs. Substantiation status is not explicitly stated.
Findings
The investigation identified a violation of the Regulations of Connecticut State Agencies Section 19-13-D105 (k) related to client service records. Specific deficiencies included failure to ensure the client's initial service plan was comprehensive and accurate, failure to identify plans for medication administration assistance, and failure to document aide care logs for November 2021.
Deficiencies (1)
Failure to ensure client’s initial Service plan was comprehensive and reflected evaluation of all client’s needs and/or client’s charts were complete and accurate.
Report Facts
Complaint number: 31734
Effective date for plan of correction: May 8, 2022
Audit percentage: 50
Audit frequency: 4
Audit frequency: 2
Audit duration: 1
Audit percentage: 25
Audit duration: 3
Audit duration: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Elizabeth T Heiney | Supervising Nurse Consultant | Signed the letter regarding the complaint investigation and plan of correction |
Inspection Report
Renewal
Capacity: 13
Deficiencies: 0
Date: Sep 27, 2021
Visit Reason
The inspection was conducted as a renewal licensing inspection for the facility.
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
Licensed Bed Capacity: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Peg Sullivan | Executive Director | Personnel contacted during the inspection |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Sep 12, 2019
Visit Reason
An unannounced visit was made to BAL Windsor on September 12, 2019 by a representative of the Facility Licensing and Investigations Section of the Department of Public Health for the purpose of conducting multiple investigations.
Complaint Details
The investigation was complaint-related, focusing on one client (Client #1) who fell due to failure of ALSA aide to perform required safety checks from 11:00 pm on 04/13/19 to 7:00 am on 04/14/19. The aide documented completing checks but did not do so and was terminated. The client was hospitalized with acute kidney injury secondary to rhabdomyolysis, mechanical fall, and pneumonia, then discharged to skilled nursing for rehabilitation.
Findings
The Assisted Living Services Agency (ALSA) failed to ensure the safety of one client with a history of falls, failed to perform required safety checks, and failed to maintain authentic records. An ALSA aide did not perform safety checks during a night shift, resulting in the client falling and being hospitalized. The aide was terminated following the investigation.
Deficiencies (1)
Failure to ensure client safety and authenticity of records related to safety checks for a client with a history of falls.
Report Facts
Date of visit: Sep 12, 2019
Date of client admission: Feb 21, 2018
Date of fall incident: Apr 14, 2019
Date of hospital discharge: Apr 20, 2019
Date client returned to ALSA: May 14, 2019
Plan of correction submission deadline: Jan 9, 2021
Date measures will be effective: Feb 15, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Loan Nguyen | Supervising Nurse Consultant | Signed letter regarding violation and investigation |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Oct 4, 2018
Visit Reason
The inspection visit was conducted as a complaint investigation related to Complaint Investigation #24165.
Complaint Details
Complaint Investigation #24165 was the reason for the visit. The complaint was not substantiated as no violations were found.
Findings
No violations of the General Statutes of Connecticut and/or regulations of Connecticut State Agencies were identified at the time of this inspection.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joel Garcia | RN | Personnel contacted during the inspection. |
| Douglas Murphy | ED | Personnel contacted during the inspection. |
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Oct 4, 2018
Visit Reason
An unannounced visit was made to BAL Windsor on October 4, 2018 by a representative 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 as it was an unannounced investigation by the Department of Public Health. The report notes violations found during the investigation and requires submission of a plan of correction by January 8, 2021.
Findings
The Assisted Living Services Agency (ALSA) failed to ensure the service plan reflected the client's problems and needs, failed to develop a comprehensive Memorandum of Understanding (MOU) with the home care agency, and failed to develop nursing policies on wound care. Specific deficiencies included lack of instructions for wheelchair use, inadequate wound care policies, failure to ensure reinforcement or replacement of dressings, and incomplete MOUs with home care agencies.
Deficiencies (5)
Service plan did not reflect client's problems and needs, lacked comprehensive MOU with home care agency, and lacked nursing policies on wound care.
Failure to identify instructions for wheelchair use with or without leg rests to prevent injury.
Failure to identify instructions on the use of pillow boots and/or leg elevation for wound care.
Failure to identify wound care provided by ALSA nurse and provisions for reinforcement or replacement of dressings in absence of home care nurse.
Failure to develop a policy on wound care for ALSA nurses.
Report Facts
Dates of visit: Oct 4, 2018
Plan of correction submission deadline: Jan 8, 2021
Client sample size: 6
Client admission date: May 6, 2017
Plan of care date: May 17, 2018
Nurse note date: Jun 24, 2018
Nursing note date: Jul 24, 2018
Home care nurse documentation date: Aug 1, 2018
Home care nurse documentation date: Aug 17, 2018
Nurse note date: Aug 18, 2018
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Loan Nguyen | Supervising Nurse Consultant | Signed the inspection report and communicated about violations |
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