Inspection Report Summary
The most recent inspection on November 18, 2024, identified deficiencies related to medication security and handling, specifically involving discrepancies with morphine oral solution bottles. Earlier inspections showed a pattern of issues including client safety concerns such as falls and injuries, medication management errors, and failure to prevent abuse, with substantiated complaints involving unauthorized charges and improper staff conduct. Complaint investigations confirmed failures in following controlled substance policies and ensuring client safety, with some staff terminations and suspensions noted. Enforcement actions such as license approval were granted despite these findings, and fines or license suspensions were not listed in the available reports. The inspection history indicates ongoing challenges with medication security and client safety, with no clear improvement trend in recent inspections.
Deficiencies (last 7 years)
Deficiencies (over 7 years)
3.1 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
45% better than Connecticut average
Connecticut average: 5.6 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
86% occupied
Based on a October 2024 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Plan of Correction
Deficiencies: 2
Nov 18, 2024
Visit Reason
An unannounced visit was made to Bal Waterbury on November 18, 2024, by the Department of Public Health for the purpose of conducting a complaint investigation.
Findings
The investigation found that the agency failed to ensure the security, safety, and integrity of clients' controlled substance medications, including a discrepancy with a morphine bottle and medication errors related to morphine oral solution bottles. The agency staff failed to follow proper procedures for handling controlled substances and client property.
Complaint Details
Complaint investigation #41746. The complaint involved medication discrepancies and errors related to morphine oral solution bottles, with involvement of local police, Department of Social Services-Elder Protective Services, Hospice agency, and Pharmacy.
Deficiencies (2)
| Description |
|---|
| The agency staff failed to ensure the security of controlled medication and safety of the client and his/her controlled substance medication. |
| The agency staff failed to identify the safe handling of the client's property and staff adherence to the agency policy. |
Report Facts
Medication discrepancy: 10
Compliance date for plan of correction: 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Elizabeth Heiney | Supervising Nurse Consultant | Author of the plan of correction letter |
Inspection Report
Complaint Investigation
Deficiencies: 1
Nov 18, 2024
Visit Reason
An unannounced visit was made to Bal Waterbury on November 18, 2024, by a representative of the Facility Licensing and Investigations Section of the Department of Public Health for the purpose of conducting a complaint investigation.
Findings
The agency failed to ensure the security, safety, and integrity of clients' controlled substance medications, specifically morphine oral solution bottles, as documented through interviews, record reviews, and investigation findings involving medication discrepancies and improper handling by staff.
Complaint Details
Complaint #41746 was investigated, with findings including medication discrepancies and failure to secure controlled substances. The complaint was substantiated as the agency failed to ensure medication safety and security.
Deficiencies (1)
| Description |
|---|
| Failure to ensure the security, safety, and integrity of clients' controlled substance medications per agency policy, including discrepancies in morphine oral solution bottles and improper handling by staff. |
Report Facts
Medication discrepancy amount: 10
Date of visit: Nov 18, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Elizabeth Heiney | Supervising Nurse Consultant | Signed letter and contact for questions regarding instructions |
Inspection Report
Plan of Correction
Deficiencies: 1
Oct 17, 2024
Visit Reason
An unannounced visit was made to Bal Waterbury on October 17, 2024, by a representative of the Facility Licensing and Investigations Section of the Department of Public Health for the purpose of conducting multiple investigations and a licensure renewal inspection.
Findings
The Assisted Living Services Agency (ALSA) failed to ensure client safety, including incidents where clients were pushed or injured by aides, resulting in a client being admitted to a hospital with a hip fracture and requiring admission to a Skilled Nursing Facility. The agency also failed to ensure proper supervision and safety measures for clients at risk of falls.
Complaint Details
Complaint CT #s 38478, 38479. The investigation included review of clinical records, agency policies, documentation, and staff interviews related to incidents involving clients #2, #3, #4, and #5. The findings substantiated failure to ensure client safety.
Deficiencies (1)
| Description |
|---|
| The agency failed to ensure the clients' safety, including incidents of client pushing and falls resulting in injury and hospitalization. |
Report Facts
Complaint numbers: 2
Medication dosage: 125
Medication dosage: 25
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Elizabeth T. Heiney | Supervising Nurse Consultant | Signed letter and contact for response regarding plan of correction |
Inspection Report
Complaint Investigation
Deficiencies: 1
Oct 17, 2024
Visit Reason
An unannounced visit was made to Bal Waterbury on October 17, 2024, 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 complaint CT #41355.
Findings
The investigation found that Licensed Practical Nurses (LPNs) failed to follow the agency's Controlled Substance Narcotic policy in medication management for one client receiving Assisted Living Service Agency (ALSA) services. Specifically, there were documentation omissions and failure to follow controlled substance inventory procedures.
Complaint Details
Complaint CT #41355 was investigated. The findings included failure by LPNs to follow controlled substance narcotic policy in medication administration and documentation for Client #6. The complaint was substantiated as violations were identified.
Deficiencies (1)
| Description |
|---|
| The agency failed to ensure Licensed Practical Nurses (LPNs) followed the agency's Controlled Substance Narcotic policy. |
Report Facts
Complaint number: 41355
Client number: 6
Medication dosage: 0.25
Medication administration dates: 12
Medication tablet count: 60
Medication tablet count: 47
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Elizabeth T. Heiney | Supervising Nurse Consultant | Author of the letter and contact for response regarding the complaint investigation. |
| LPN #1 | Identified documentation omission on controlled substance inventory balance sheet for medication administration on 10/09/2024. | |
| LPN #2 | Administered medication doses and failed to notify supervisor of documentation omission. | |
| RN Designee | Registered Nurse Designee | Reviewed clinical record and signed controlled substance inventory balance sheet; identified failures to follow controlled substance narcotic policy. |
Inspection Report
Plan of Correction
Deficiencies: 1
Oct 17, 2024
Visit Reason
The inspection was an unannounced visit conducted on October 17, 2024, by the Facility Licensing and Investigations Section of the Department of Public Health to investigate a complaint regarding the facility's compliance with regulations.
Findings
The agency failed to ensure client safety, specifically failing to ensure a client was free from abuse and that an ALSA aide followed the agency's Code of Conduct. The investigation found unauthorized charges on a client's credit card by an ALSA aide, who was subsequently terminated for failing to follow abuse, neglect, and exploitation policies.
Complaint Details
The visit was complaint-related, investigating allegations of abuse and failure to follow agency policies. The complaint number is CT #38379. The findings substantiated that abuse occurred involving unauthorized charges by an ALSA aide.
Deficiencies (1)
| Description |
|---|
| The agency failed to ensure a client was free from abuse and failed to ensure an ALSA aide followed the agency's Code of Conduct, including unauthorized charges on a client's credit card and failure to follow Abuse, Neglect and Exploitation Prohibition and Prevention policy. |
Report Facts
Date of inspection visit: Oct 17, 2024
Plan of correction submission deadline: Nov 8, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Danielle Galazzo | Resident Care Director | Author of the Plan of Correction letter |
| Elizabeth T. Heiney | Supervising Nurse Consultant | Recipient of the Plan of Correction and author of the violation notice |
| Christopher Lathrop | Executive Director | Named in the violation letter and investigation |
Inspection Report
Renewal
Census: 141
Capacity: 164
Deficiencies: 0
Oct 17, 2024
Visit Reason
The inspection was conducted as a licensing renewal inspection and included review of a complaint investigation #38379.
Findings
Violations of the General Statutes of Connecticut and/or regulations of Connecticut State Agencies were identified at the time of this inspection. Approval for issuance of license was granted.
Complaint Details
Complaint investigation #38379 was reviewed as part of this inspection.
Report Facts
Licensed Bed Capacity: 164
Census: 141
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Christopher Lathrop | Executive Director | Personnel contacted during inspection |
| Danielle Galasso | SALSA | Personnel contacted during inspection |
| Kassandra Pichardo | RND | Personnel contacted during inspection |
| Megan Edson-Sawyer | Survey Team Leader | Report submitted by |
| Elizabeth Heiney | Supervisor | Supervisor of survey team |
Inspection Report
Plan of Correction
Deficiencies: 2
Feb 28, 2024
Visit Reason
An unannounced visit was made to Bal Waterbury on February 28, 2024, by a representative of the Facility Licensing and Investigations Section of the Department of Public Health for the purpose of conducting an investigation with additional information received through February 29, 2024.
Findings
Two violations of the Regulations of Connecticut State Agencies were identified related to failure of an Assisted Living Services Agency aide to follow agency policies on Code of Conduct and failure of the Supervisor of Assisted Living Services Agency to update the client service plan every 120 days as required by State Regulations.
Complaint Details
Complaint CT #37705 triggered the investigation.
Deficiencies (2)
| Description |
|---|
| Assisted Living Services Agency aide failed to follow agency policies on Code of Conduct, including unprofessional conduct and poor treatment of residents. |
| Supervisor of Assisted Living Services Agency failed to update the client service plan every 120 days in accordance with State Regulations. |
Report Facts
Compliance Date: 2024.04
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Elizabeth T. Heiney | Supervising Nurse Consultant | Signed letter and contact for response regarding plan of correction. |
Inspection Report
Monitoring
Deficiencies: 0
Nov 1, 2023
Visit Reason
The inspection was conducted as a strike monitoring supplement to the licensing inspection report for The Village at East Farms 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, as indicated on page 1 of the report.
Complaint Details
Complaint Investigation #35771 was referenced but no details or substantiation status were provided.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Megan Edson-Sawyer | Survey Team Leader and Nurse Consultant | Named as Survey Team Leader and Report Submitter for the inspection. |
| Chris Lathrop | Executive Director | Personnel contacted during the inspection. |
| Megan Kubik | SALSA | Personnel contacted during the inspection. |
| Elizabeth Heiney | Supervisor | Named as Supervisor on the report. |
Inspection Report
Renewal
Census: 164
Capacity: 328
Deficiencies: 0
Aug 25, 2022
Visit Reason
The inspection visit was conducted for licensing inspection and renewal purposes, including verification of Alzheimer's special care units and infection prevention requirements.
Findings
No violations of the General Statutes of Connecticut or regulations of Connecticut State Agencies were identified at the time of this inspection.
Report Facts
Memory Care/Traditional Capacity: 41
Memory Care/Traditional Capacity: 110
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Karen Donato | RNC | Report submitted by |
| Liz Skerry-Hastings | ED | Personnel contacted |
| Megan Kubik | SALSA | Personnel contacted |
Inspection Report
Renewal
Census: 164
Capacity: 328
Deficiencies: 0
Aug 25, 2022
Visit Reason
The inspection visit was conducted for the purpose of a renewal licensing inspection of 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. Verification of Alzheimer's special care units and full-time infection prevention and control specialist requirements were confirmed.
Report Facts
Census: 164
Total Capacity: 328
Memory Care/Traditional Capacity: 41
Memory Care/Traditional Capacity: 110
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Karen Donato | RN Nurse Consultant | Signature of FLIS Staff conducting the inspection and submitting the report |
| Liz Skerry-Hastings | ED | Personnel contacted during inspection |
| Megan Kubik | SALSA | Personnel contacted during inspection |
Inspection Report
Complaint Investigation
Deficiencies: 0
Apr 4, 2022
Visit Reason
The inspection visit was conducted as a complaint investigation related to complaint CT #31935 and violations of the General Statutes of Connecticut and/or regulations of Connecticut State Agencies were identified.
Findings
Violations of the General Statutes of Connecticut and/or regulations of Connecticut State Agencies were identified at the time of the inspection. Verification of Alzheimer's special care units and full-time infection prevention and control specialist requirements were also conducted.
Complaint Details
Complaint investigation related to CT #31935 with violations identified.
Report Facts
Complaint number: 31935
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Karen Donato | RN Nurse Consultant | Signature of FLIS Staff and report submitter |
| Megan Kubik | Personnel contacted during inspection | |
| Liz Skerry-Hastings | ED | Personnel contacted during inspection |
Inspection Report
Complaint Investigation
Deficiencies: 1
Apr 4, 2022
Visit Reason
An unannounced visit was made to Bal Waterbury on April 4, 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 with additional information received through April 4, 2022.
Findings
The investigation found that a Registered Nurse failed to assess a client after a fall and/or review/revise the client service plan after the fall and failed to follow the facility fall policy. Multiple incidents were reviewed where fall evaluations and RN assessments were not completed as required.
Complaint Details
Complaint #31935 was investigated. The complaint involved failure to assess a client after a fall and failure to follow the facility fall policy.
Deficiencies (1)
| Description |
|---|
| Registered Nurse/RN failed to assess the client after a fall and/or review/revise the client service plan after the fall and failed to follow the facility fall policy. |
Report Facts
Dates of fall incident reports: Fall Incident Reports dated 8/02/21, 8/18/21, and 9/06/21 were reviewed.
Effective date of corrective measures: Nov 14, 2022
Audit frequency: 25
Audit schedule: 3
Audit schedule: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Elizabeth Heiney | Supervising Nurse Consultant | Signed the letter as Supervising Nurse Consultant from Facility Licensing and Investigations Section. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Feb 28, 2022
Visit Reason
The inspection visit was conducted as a complaint investigation related to Complaint Investigation 30705.
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 3/18/22.
Complaint Details
Complaint Investigation 30705 was the basis for the visit. Violations were substantiated as indicated by the attached violation letter.
Report Facts
Complaint Investigation Number: 30705
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Megan Edson-Sawyer | Report submitted by | |
| Megan Kubik | Personnel contacted |
Inspection Report
Complaint Investigation
Deficiencies: 0
Feb 28, 2022
Visit Reason
The visit was conducted as a complaint investigation related to Complaint Investigation 30705.
Findings
Violations of the General Statutes of Connecticut and/or regulations of Connecticut State Agencies were identified at the time of this inspection.
Complaint Details
Complaint Investigation 30705 was the reason for the visit; violations were found but no further details on substantiation are provided.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Megan Edson-Sawyer | Report submitted by |
Inspection Report
Plan of Correction
Deficiencies: 1
Feb 28, 2022
Visit Reason
Unannounced visits were made to Bal Waterbury on February 28, 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.
Findings
The Assisted Living Service Agency (ALSA) failed to protect Client #1 from physical injury and failed to follow the Client’s service plan, resulting in an injury caused by improper use of a Hoyer lift. The agency's investigation confirmed failures by ALSA aides to ensure proper repositioning and safety measures.
Complaint Details
Complaint #31705. The investigation substantiated that ALSA failed to protect Client #1 from physical injury and failed to follow the Client’s service plan.
Deficiencies (1)
| Description |
|---|
| Failure to protect Client #1 from physical injury and failure to follow the Client’s service plan, including improper use of a Hoyer lift causing injury. |
Report Facts
Date of visit: Feb 28, 2022
Plan of correction submission deadline: Mar 28, 2022
Effective date of plan of correction: Apr 30, 2022
Admission date of Client #1: Apr 22, 2011
Date of Client #1 death: Feb 24, 2022
Date of hospice admission: Mar 19, 2019
Date of incident: Jan 21, 2022
Date of service plan: Sep 14, 2021
Date of policy re-inservice: Apr 30, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Elizabeth Heiney | Supervising Nurse Consultant | Signed letter regarding complaint investigation and plan of correction instructions |
Inspection Report
Plan of Correction
Deficiencies: 3
Oct 18, 2021
Visit Reason
An unannounced visit was made to Bal Waterbury on October 18, 2021 by a representative 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 Service Agency (ALSA) failed to protect Client #1 from physical injury by not performing a comprehensive assessment after an injury, failing to update the Client's Service Program, and failing to implement infection control measures in the Client's living environment. The incident involved a laceration to the Client's forehead caused by a malfunctioning hospital bed. ALSA aides and the RN Designee failed to properly assess and respond to the injury and bed malfunction. ALSA aides #1 and #2 were terminated and the RN Designee was suspended.
Deficiencies (3)
| Description |
|---|
| Failure to perform a comprehensive assessment after Client #1 sustained an injury. |
| Failure to update Client #1's Service Program with a change in condition. |
| Failure to implement infection control measures in the Client's living environment subsequent to the injury. |
Report Facts
Dates of injury and related events: Oct 6, 2021
Plan of correction effective date: Dec 25, 2021
Audit frequency: 3
Audit frequency: 25
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Cheryl Davis | Public Health Services Manager | Signed letter regarding plan of correction instructions. |
| Megan Kubik | Supervisor of Assisted Living Services Agency | Recipient of the plan of correction letter. |
Inspection Report
Renewal
Census: 98
Deficiencies: 0
Sep 3, 2021
Visit Reason
The inspection visit 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
Number of ALSA clients: 98
Number of home visits: 3
Number of records reviewed: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Megan Kubik | Personnel contacted and report submitted by | |
| Liz Skeeny-Hastings | Personnel contacted during inspection |
Inspection Report
Plan of Correction
Deficiencies: 2
Oct 30, 2020
Visit Reason
An unannounced visit was made to BAL Waterbury on October 30, 2020 by a representative of the Facility Licensing and Investigations Section of the Department of Public Health for the purpose of conducting an investigation.
Findings
The Assisted Living Services Agency (ALSA) nurses and aides failed to follow ALSA policies and/or failed to ensure the safety of Client #1, who was at high risk for falls. Specific failures included incomplete fall evaluations and lack of implementation of interventions following a fall incident.
Deficiencies (2)
| Description |
|---|
| Failed to identify completion of a fall evaluation in accordance with the ALSA policy following each incident of fall. |
| Failed to identify implementation of the interventions developed in the plan of care following the client’s fall, such as observing the client for unsteadiness, ensuring the use of well-fitting shoes with non-skid soles, leaving the light in bathroom during evening and night shifts, making available the pull cord in bathroom, ensuring the use of the walker at all times during ambulation. |
Report Facts
Fall risk score: 10
Date of fall incident: Jun 8, 2020
Date measures effective: Jan 1, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Loan Nguyen | Supervising Nurse Consultant | Named as the contact person for the Facility Licensing and Investigations Section and signer of the report. |
| Kelly Solomon | Supervisor of Assisted Living Services Agency | Recipient of the report and plan of correction. |
Inspection Report
Plan of Correction
Census: 9
Deficiencies: 3
May 21, 2020
Visit Reason
An unannounced visit was made to Bal Waterbury on May 21, 2020 by a representative of the Facility Licensing and Investigations Section of the Department of Public Health for the purpose of conducting an investigation and a licensure inspection.
Findings
The Assisted Living Services Agency (ALSA) failed to follow federal guidelines from the CDC and proper infection control practices to prevent community spread and protect residents and staff. Specific deficiencies included improper handling and disposal of disposable gowns and Tyvek jumpsuits, failure to identify appropriate infection control measures, and inadequate hand sanitation practices.
Deficiencies (3)
| Description |
|---|
| Failed to identify policies and procedures in accordance with CDC guidelines to direct the discarding of disposable gowns after use and to differentiate between extended use and re-use of disposable gowns. |
| Failed to identify appropriate infection control measures to contain transmission and protect staff and residents. |
| Failed to identify proper disposal of Tyvek jumpsuits as a one-time use isolation protective equipment. |
Report Facts
Residents with positive COVID-19 status: 9
Date measures will be effective: Jun 15, 2020
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Loan Nguyen | Supervising Nurse Consultant | Named as contact for response to the violation letter. |
| Lee Tyburski | Executive Director | Named as recipient of the violation letter and plan of correction. |
| Memory Care Director | Interviewed regarding infection control practices and PPE use during the inspection. |
Inspection Report
Complaint Investigation
Deficiencies: 4
Apr 19, 2018
Visit Reason
The inspection was an unannounced complaint investigation conducted on April 19, 2018, to investigate allegations of mental, psychological, and emotional abuse at the assisted living services agency.
Findings
The investigation found that the facility failed to ensure the client was free from mental, psychological, and emotional abuse. Multiple ALSA aides were involved in abusive behavior including ridiculing a client with vulgar language and videotaping the client without consent. Several aides were terminated following the investigation. The facility also failed to identify and report client abuse appropriately and timely.
Complaint Details
Complaint investigation #23257 was substantiated with findings of mental, psychological, and emotional abuse by ALSA aides towards a client. The investigation included interviews, review of agency documentation, and video evidence. Several aides were terminated as a result. The facility failed to provide oversight and timely reporting of abuse and failed to conduct nursing assessments as required.
Deficiencies (4)
| Description |
|---|
| Failure to ensure the client was free from mental, psychological, and emotional abuse. |
| Failure to identify protection of the client's rights to be free from mental and emotional abuse by the Supervisor of Assisted Living Agency Services. |
| Failure to identify appropriate and timely reporting of client abuse by ALSA aides. |
| Failure to identify nursing assessment of the client's emotional and/or psychological status from 3/27/18 until the time of the survey on 4/19/18. |
Report Facts
Complaint Investigation Number: 23257
Date of onsite inspection: April 19, 2018 (date extracted as report_date)
Number of ALSA aides terminated: 5
Date of office conference: June 14, 2018 at 1:00 PM scheduled for discussion of violations.
Date measures effective: June 20, 2018, date when corrective measures were to be effective.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Deborah Daniel | Supervisor of Assisted Living Services Agency | Named as personnel contacted and Resident Care Director who submitted the Plan of Correction. |
| Loan Nguyen | Supervising Nurse Consultant | Named as the supervisor approving issuance of license and author of violation letters. |
Inspection Report
Renewal
Census: 146
Capacity: 176
Deficiencies: 0
May 2, 2017
Visit Reason
The inspection was conducted as a renewal licensing inspection for the 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.
Report Facts
Licensed Bed Capacity: 176
Census: 146
Inspection Dates: 3
Records Reviewed: 4
Home Visits: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Deborah Daniel | SALSA | Personnel contacted during inspection |
| Lee Ann Tyburski Johnson | Personnel contacted during inspection | |
| Mary Gutberletka | Regional Nurse | Personnel contacted during inspection |
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