Inspection Reports for The Village at Kensington Place

CT, 06451

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Inspection Report Plan of Correction Deficiencies: 1 Oct 7, 2024
Visit Reason
An unannounced visit was made on October 7, 2024, by a representative of the Facility Licensing and Investigations Section of the Department of Public Health to conduct a complaint investigation survey.
Findings
The report identifies a violation where the Supervisor of Assisted Living Services failed to provide supervision of assigned assisted living aides and ensure the safety of a client during a transfer, resulting in injury and hospital transport. The agency failed to identify supervision of aides and ensure client safety.
Complaint Details
The visit was complaint-related under Complaint #40747. The complaint involved failure to supervise assisted living aides and ensure client safety, resulting in injury. Substantiation status is not explicitly stated.
Deficiencies (1)
Description
Supervisor of Assisted Living Services failed to provide supervision of assigned assisted living aides and ensure the safety of Client #3 during a transfer, resulting in injury and hospital transport.
Report Facts
Complaint number: 40747 Date of visit: Oct 7, 2024 Plan of correction submission deadline: Oct 31, 2024 Compliance date: Nov 30, 2024
Employees Mentioned
NameTitleContext
Elizabeth HeineySupervising Nurse ConsultantAuthor of the letter and contact for plan of correction
Jody DonaExecutive DirectorFacility Executive Director addressed in the letter
Inspection Report Plan of Correction Deficiencies: 1 Oct 7, 2024
Visit Reason
An unannounced visit was made to Bal Meriden on October 7, 2024, 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 identified violations related to failure to ensure client safety, coordinate services, and update service plans in accordance with agency policies and state regulations. Specific incidents included client altercations and failure to assess and update client behaviors and medication needs.
Complaint Details
The visit was complaint-related under Complaint CT #41193. The complaint involved incidents of client altercations and failure to ensure safety and proper care.
Deficiencies (1)
Description
Failure to ensure client safety, coordinate services, and update service plans for clients receiving assisted living services, including failure to assess client behaviors and medication needs.
Report Facts
Complaint number: 41193 Plan of correction submission deadline: Oct 31, 2024 Date of visit: Oct 7, 2024 Client service plan dates: Jun 5, 2024 Client service plan dates: Jun 24, 2024 Client service plan dates: Feb 12, 2024 Client service plan dates: Jun 11, 2024 Medication dosage: 25 Medication dosage: 12.5 Assessment frequency: 120
Employees Mentioned
NameTitleContext
Elizabeth T. HeineySupervising Nurse ConsultantSigned letter and contact for plan of correction response
Inspection Report Renewal Census: 110 Capacity: 134 Deficiencies: 0 Aug 2, 2024
Visit Reason
The inspection was a licensing renewal inspection conducted to review compliance with state regulations and verify facility operations.
Findings
No violations of the General Statutes of Connecticut or regulations were identified at the time of this inspection. The re-licensure survey included a tour and review of various facility documents such as meeting minutes, personnel folders, staffing schedules, and clinical record reviews.
Report Facts
Memory care capacity: 24
Employees Mentioned
NameTitleContext
Jody Abel DonaExecutive DirectorPersonnel contacted during inspection
Erica TuckerPersonnel contacted during inspection
Michael J. SmithNurse ConsultantInspection report submitted by
Inspection Report Plan of Correction Deficiencies: 1 Oct 30, 2023
Visit Reason
An unannounced visit was made to Bal Meriden on October 30, 2023 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) failed to follow the agency's Significant Changes in a Client's Status and Elopement Risk Assessment and Interventions policy, specifically failing to identify and update the client's elopement risk assessment and service plan based on changes in condition to ensure client safety.
Complaint Details
Complaint #35259 triggered the investigation.
Deficiencies (1)
Description
Failure to follow the agency's Significant Changes in a Client's Status and Elopement Risk Assessment and Interventions policy, including failure to identify the client's elopement risk and update the service plan accordingly.
Report Facts
Dates: Oct 30, 2023 Effective Date: Dec 1, 2023
Employees Mentioned
NameTitleContext
Elizabeth HeineySupervising Nurse ConsultantAuthor of the plan of correction letter and contact for response
Inspection Report Complaint Investigation Deficiencies: 0 Oct 30, 2023
Visit Reason
The inspection visit was conducted as a complaint investigation related to Complaint Investigation #35259.
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 dated 11/8/23.
Complaint Details
Complaint Investigation #35259 was the reason for the visit; violations were found and documented in an attached violation letter dated 11/8/23.
Employees Mentioned
NameTitleContext
Jody Abel DonaExecutive DirectorPersonnel contacted during the inspection.
Kebra Smith-BoldenSALSAPersonnel contacted during the inspection.
Elizabeth HeineySurvey Team LeaderNamed as Survey Team Leader.
Megan Edson-SawyerSupervisorNamed as Supervisor.
Inspection Report Renewal Census: 84 Deficiencies: 0 Aug 18, 2022
Visit Reason
The inspection was conducted as a licensing inspection for renewal purposes, including verification of Alzheimer's special care units and compliance with infection prevention and control requirements.
Findings
The report indicates that the facility was reviewed for licensing renewal and compliance with applicable regulations, including a review of the plan of correction dated 9/17/21. No violations or citations were issued at the time of this inspection.
Report Facts
Census: 84 Alzheimer's special care units: 68 Memory care residents: 16
Employees Mentioned
NameTitleContext
Michael J. SmithRN Nurse ConsultantReport submitted by
Jody Abel DonaEx. DirectorPersonnel contacted during inspection
Roland GarciaRN, SALSAPersonnel contacted during inspection
Inspection Report Renewal Census: 84 Capacity: 134 Deficiencies: 0 Aug 18, 2022
Visit Reason
The inspection was conducted as a licensing renewal inspection for the ALSA facility, BAL Meriden/Village Kensington Place.
Findings
No violations of the General Statutes of Connecticut or regulations were identified at the time of this inspection. The previously reviewed Plan of Correction dated 9/17/21 was also reviewed during this inspection.
Report Facts
Census: 84 Total Capacity: 134
Employees Mentioned
NameTitleContext
Michael J. SmithNurse ConsultantReport submitted by and signature on inspection report
Jody Abel DonaEx. DirectorPersonnel contacted during inspection
Roland GarciaRN, SALSAPersonnel contacted during inspection
Inspection Report Renewal Capacity: 134 Deficiencies: 0 Sep 27, 2021
Visit Reason
The inspection was conducted as a licensing renewal 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.
Employees Mentioned
NameTitleContext
Tammy KuczynskiSALSA DesigneePersonnel contacted during the inspection.
David PiminiService CoordinatorPersonnel contacted during the inspection and managed residential community visited.
Inspection Report Complaint Investigation Census: 60 Deficiencies: 1 Sep 17, 2021
Visit Reason
An unannounced visit was made to Bal Meriden on September 17, 2021, by a representative of the Facility Licensing and Investigations Section of the Department of Public Health for the purpose of conducting a complaint survey.
Findings
The agency failed to respond timely to clients' emergency pendant alarms and failed to ensure adequate staffing to meet clients' needs. Multiple instances of delayed response times to emergency calls were documented, and staffing was found inadequate on several dates in August 2021.
Complaint Details
Complaint #30737 triggered the investigation. The Executive Director failed to adequately investigate delays in service call response and failed to ensure adequate staffing to meet client needs.
Deficiencies (1)
Description
Failure to respond timely to clients' emergency pendant alarms and failure to ensure adequate staffing to meet clients' needs.
Report Facts
Census: 60 Staffing ratio: 3 Response times: Multiple response times to emergency pendant alarms ranged from 12 minutes to over 40 minutes, exceeding the agency's policy of responding within seven minutes.
Employees Mentioned
NameTitleContext
Cheryl DavisPublic Health Services ManagerSigned letter regarding the complaint survey and instructions.
Tiffany KuczynskiRN SALSARecipient of the inspection report and plan of correction.
Inspection Report Plan of Correction Deficiencies: 5 Jan 16, 2020
Visit Reason
Unannounced visits were made to BAL Meriden on November 21, 2018, December 18, 2019, and January 16, 2020 by representatives of the Facility Licensing and Investigations Section of the Department of Public Health for the purpose of conducting multiple investigations.
Findings
Multiple violations of Connecticut State Agencies regulations and General Statutes were identified, including failure of the governing authority to develop policies conforming to state regulations, inadequate staffing response times, failure to provide appropriate dementia training, and failure to properly review and document client care plans and assessments.
Deficiencies (5)
Description
The governing authority failed to develop policies to conform to State regulations, including failure to notify the ALSA registered nurse or EMS after a client fall and unsafe handling of the client.
Executive Director failed to investigate delays in service call response and SALSA failed to ensure adequate staffing to meet client needs.
ALSA failed to ensure provision of appropriate dementia training for an aide assigned to care for clients with dementia.
SALSA/registered nurse failed to review aide documentation of care for clients requiring ALSA aide services.
SALSA/registered nurse failed to ensure client service plan and instructions included need for wheelchair for a client requiring one.
Report Facts
Dates of visits: November 21, 2018, December 18, 2019, January 16, 2020 Call pendant response times: 25 Dementia training hours missing: 8 Dates of hire and admission: Employee hire date 3/16/16; Client admissions 5/23/14, 12/10/19, 1/8/13, 5/25/18
Employees Mentioned
NameTitleContext
Loan NguyenSupervising Nurse ConsultantSigned the notice letter regarding violations
Mary Lou FahySenior Regional Director of Resident CareAddressee of the notice letter
LPN #10Named in findings related to client fall and failure to notify ALSA RN or EMS
Executive DirectorNamed in findings related to failure to investigate delays in service call response
ALSA Aide #4Named in findings related to failure to provide dementia training
RN #1Named in findings related to failure to review aide documentation
Inspection Report Renewal Census: 103 Deficiencies: 0 Nov 21, 2018
Visit Reason
The inspection was conducted as a renewal licensing inspection and included a complaint investigation (Complaint Investigation #20673).
Findings
Violations of the General Statutes of Connecticut and/or regulations of Connecticut State Agencies were identified at the time of the inspection. Approval for issuance of license was granted.
Complaint Details
Complaint Investigation #20673 was referenced in the inspection report, but no substantiation status was explicitly stated.
Report Facts
Number of ALSA clients: 103 Number of home visits: 2 Number of records reviewed: 3
Employees Mentioned
NameTitleContext
Denise Jones ColemanSupervisorPersonnel contacted during inspection
William AllenExecutive DirectorPersonnel contacted during inspection
Noben BarriosReport submitted by
Loan Q NguyenSupervisorApproval for issuance of license granted by
Inspection Report Complaint Investigation Census: 82 Deficiencies: 3 Feb 21, 2017
Visit Reason
The inspection was conducted as a complaint investigation (#20693) and licensing inspection at The Village at Kensington Place, an assisted living services agency.
Findings
The inspection identified violations related to failure to ensure participation of clients or families in the development of client service programs, failure to maintain required personnel files documentation, and failure to coordinate hospice services. Deficiencies were documented with corrective measures and timelines.
Complaint Details
Complaint investigation #20693 was conducted based on allegations related to client service program participation, personnel file documentation, and hospice service coordination. The complaint was substantiated with identified violations.
Deficiencies (3)
Description
Failure to ensure participation of clients or families in the development of client service programs for multiple clients.
Failure to identify documentation of 2016 annual physical examinations and tuberculin testing for ALSA aides #2, #3, #4, and #5 personnel files.
Failure to coordinate hospice services with the hospice agency for a client receiving hospice care.
Report Facts
Census: 82 Number of home visits: 2 Number of records reviewed: 5 Date measures will be effective: 2017
Employees Mentioned
NameTitleContext
William AllynExecutive DirectorSigned plan of correction letter
Christine SampsonSupervisor of Assisted Living Services AgencyNamed as personnel contacted and supervisor in findings
Inspection Report Complaint Investigation Census: 32 Deficiencies: 0 Feb 14, 2017
Visit Reason
The inspection was conducted as a renewal licensing inspection and included a complaint investigation (Complaint Investigation #20693).
Findings
Violations of the General Statutes of Connecticut and/or regulations were identified at the time of this inspection. The report references attached violation letters but does not detail specific deficiencies in the pages provided.
Complaint Details
Complaint Investigation #20693 was conducted; substantiation status is not explicitly stated.
Report Facts
Census: 32
Employees Mentioned
NameTitleContext
Christine SampsonResident Care DirectorPersonnel contacted during inspection and author of email regarding license expiration
Rose McLellanLicense & Applications SupervisorAuthor of letter responding to license expiration inquiry
Loan NguyenSupervising Nurse ConsultantContact person mentioned for questions regarding license renewal

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