Inspection Report Summary
The most recent inspection on January 6, 2025, identified deficiencies related to state statutes and regulations. Earlier inspections showed a mixed pattern, with some renewal inspections finding no violations, such as the December 6, 2024 renewal inspection, while complaint investigations in late 2023 and earlier noted multiple issues involving resident care, documentation, staffing, and environmental safety. Complaint investigations substantiated violations including failure to notify Power of Attorney of condition changes, inadequate wound and skin assessments, and insufficient staffing levels. Enforcement actions such as fines or license suspensions were not listed in the available reports. The inspection history indicates ongoing challenges with resident care and compliance, with some periods of correction followed by recurring deficiencies.
Deficiencies (last 6 years)
Deficiencies (over 6 years)
5.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
4% worse than Connecticut average
Connecticut average: 5.6 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
94% occupied
Based on a January 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Renewal
Census: 85
Capacity: 90
Deficiencies: 0
Jan 6, 2025
Visit Reason
The inspection was conducted as a renewal licensing inspection for the facility Autumn Lake at Bucks Hill.
Findings
Violations of the General Statutes of Connecticut and/or regulations of Connecticut State Agencies were identified during the inspection, with an attached violation letter dated 2025-01-06.
Report Facts
Licensed Bed Capacity: 90
Census: 85
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Krista Wagner | Administrator | Personnel contacted during inspection |
| Ariel Colon | DNS | Personnel contacted during inspection |
Inspection Report
Renewal
Census: 85
Capacity: 90
Deficiencies: 0
Dec 6, 2024
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: 90
Census: 85
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Krista Wagner | Administrator | Personnel contacted during inspection |
| Aniel Colon | DNS | Personnel contacted during inspection |
Inspection Report
Complaint Investigation
Deficiencies: 12
Dec 6, 2024
Visit Reason
An unannounced visit was conducted at Autumn Lake Healthcare At Bucks Hill to investigate multiple complaints and concerns related to resident care, facility compliance with regulations, and safety.
Findings
The facility was found to have multiple violations including failure to obtain signed advance directives, failure to report lost resident property timely, failure to prevent decline in resident mobility, inadequate nail care, failure to follow hospital discharge orders, inadequate pressure ulcer assessments, failure to apply ordered splints, failure to monitor resident weights and nutrition properly, serving food at unsafe temperatures, inadequate dishwasher sanitization, improper use of PPE during care, and unsafe, unsanitary environmental conditions in a tub room.
Complaint Details
The visit was complaint-related, investigating multiple issues including advance directives, lost personal property, decline in resident function, infection control, nutrition, and environmental safety. Substantiation status is not explicitly stated.
Deficiencies (12)
| Description |
|---|
| Failed to ensure advance directives consent was signed and available for Resident #329. |
| Failed to report loss of Resident #27's personal belonging to the State Agency within 24 hours. |
| Failed to prevent decline in transfer and ambulation abilities for Resident #44. |
| Failed to maintain clean and trimmed fingernails for Resident #22. |
| Failed to follow hospital discharge order for specialist consultation for Resident #5. |
| Failed to ensure weekly skin checks and RN assessment for pressure ulcer for Resident #39. |
| Failed to apply left wrist hand splint as ordered for Resident #22. |
| Failed to properly monitor nutrition and weights for Residents #44 and #281. |
| Failed to serve resident food at safe and appetizing temperatures. |
| Failed to maintain dishwasher temperatures to adequately sanitize dishware. |
| Failed to ensure appropriate PPE use during high contact care for residents on Enhanced Barrier Precautions. |
| Failed to provide a homelike, sanitary, and safe environment in the Westwood Unit tub room. |
Report Facts
Weight loss: 6.6
Missed ambulation opportunities: 36
Missed ambulation opportunities: 41
Missed ambulation opportunities: 56
Dishwasher wash temperature: 148
Dishwasher rinse temperature: 150
Food temperature - pork chops: 118
Food temperature - mashed potatoes: 119.4
Food temperature - hot beets: 111
Food temperature - milk: 46
Resident weight: 114.2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Laura Trombley Norton | Supervising Nurse Consultant | Author of the amended violation letter. |
| Krista Wagner | Administrator | Facility administrator named in multiple findings. |
| APRN #1 | Interviewed regarding advance directives and nephrology follow-up. | |
| NA #3 | Nurse Aide | Interviewed regarding ambulation, nail care, and weight monitoring. |
| LPN #2 | Licensed Practical Nurse | Interviewed regarding ambulation and pressure ulcer assessments. |
| PT #1 | Physical Therapist | Interviewed regarding ambulation and splinting. |
| RN #1 | Registered Nurse | Interviewed regarding advance directives and weight monitoring. |
| Dietician | Interviewed regarding resident weight monitoring and nutrition. | |
| Director of Food Services | Interviewed regarding dishwasher temperatures and food service. | |
| NA #2 | Nurse Aide | Observed and interviewed regarding PPE use. |
| NA #1 | Nurse Aide | Observed and interviewed regarding PPE use. |
| DNS | Director of Nursing Services | Interviewed regarding multiple findings including PPE, pressure ulcers, and weight monitoring. |
| Maintenance Director | Interviewed regarding environmental conditions in tub room. |
Inspection Report
Follow-Up
Census: 84
Capacity: 90
Deficiencies: 0
Jan 17, 2024
Visit Reason
The visit was a desk audit conducted on 1/16/24 and 1/17/24 to review the implementation of the plan of correction for violations previously identified.
Findings
All violations (#1, #2, #3, and #4) were corrected as of 12/27/23, and the Administrator was notified on 1/17/24 that all violations were corrected.
Report Facts
Violations corrected: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Suzanne Morello | RN, BSN, NC | Report submitted by and signed off on correction notification |
| Jessica Lindsay | Personnel contacted during inspection | |
| Krista Wagner | Personnel contacted during inspection |
Inspection Report
Complaint Investigation
Census: 84
Capacity: 90
Deficiencies: 5
Nov 15, 2023
Visit Reason
The inspection was conducted as a complaint investigation related to Complaint #36395 at Autumn Lake Healthcare at Bucks Hill.
Findings
The investigation identified multiple violations related to failure to notify Power of Attorney upon change in condition, inadequate wound assessments, failure to conduct weekly skin assessments, failure to obtain ordered laboratory blood work, and staffing levels not meeting minimum requirements.
Complaint Details
Complaint #36395 triggered the inspection. The complaint was substantiated with findings of noncompliance in multiple areas including resident care and staffing.
Deficiencies (5)
| Description |
|---|
| Failure to notify Power of Attorney when Resident #1 experienced a change in condition and failure to document related interventions. |
| Failure to conduct and document an initial wound assessment when blisters were identified on Resident #1. |
| Failure to conduct and document weekly skin assessments as ordered by the physician for Resident #1. |
| Failure to follow physician's order to obtain laboratory blood work for Resident #1. |
| Failure to maintain staffing levels to meet minimum requirements according to the Connecticut Public Health Code. |
Report Facts
Licensed beds: 90
Census: 84
Staffing hours required: 132.8
Staffing hours scheduled: 120
Residents sampled: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Krista Wagner | Administrator | Personnel contacted during inspection and referenced in findings. |
| Karen Gworek | Supervising Nurse Consultant | Author of the notice letter regarding the inspection findings. |
| Aneta Predka | RN | Report submitted by this nurse on 11/17/23. |
Inspection Report
Complaint Investigation
Census: 84
Capacity: 90
Deficiencies: 4
Nov 15, 2023
Visit Reason
The inspection was conducted as a complaint investigation (#36395) following allegations of violations of Connecticut State regulations at Autumn Lake Healthcare at Bucks Hill.
Findings
The investigation identified multiple violations related to failure to notify Power of Attorney of condition changes, incomplete wound assessments, failure to conduct weekly skin assessments, and failure to obtain ordered laboratory blood work for a resident. The facility was required to submit a plan of correction.
Complaint Details
Complaint #36395 was investigated. Violations were substantiated as the facility failed to comply with regulations regarding resident care and documentation.
Deficiencies (4)
| Description |
|---|
| Failure to notify Power of Attorney at time of resident's change in condition and failure to document related interventions. |
| Failure to conduct and document initial wound assessment when blisters were identified on a resident. |
| Failure to conduct and document weekly skin assessments as ordered by physician. |
| Failure to follow physician's order to obtain laboratory blood work for a resident. |
Report Facts
Licensed Bed Capacity: 90
Resident Census: 84
Plan of Correction Submission Deadline: Plan of correction was to be submitted by December 17, 2023.
Random Audits Frequency: 3
Audit Duration: 60
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Krista Wagner | Administrator | Personnel contacted during the inspection. |
| Aneta Predka | RN | Report submitted by this registered nurse. |
| Karen Gworek | Supervising Nurse Consultant | Signed the amended violation letter. |
| Registered Nurse #1 | Registered Nurse | Identified failures in notification and documentation related to Resident #1. |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Interviewed regarding wound assessment documentation. |
| Director of Nursing | Responsible for plan of correction and conducting audits. |
Inspection Report
Renewal
Census: 81
Capacity: 96
Deficiencies: 4
Aug 22, 2022
Visit Reason
Unannounced visits were made to Autumn Lake Healthcare At Bucks Hill for the purpose of conducting a licensing and certification survey, including a renewal licensing inspection.
Findings
Violations of the General Statutes of Connecticut and/or regulations were identified during the inspection, including failures related to resident council concerns, housekeeping and maintenance issues, clinical record documentation, and coding of mental health assessments.
Deficiencies (4)
| Description |
|---|
| Facility failed to respond to resident council concerns regarding weekend activities and housekeeping issues. |
| Resident room #7 and shower room on Woodbridge unit were not cleaned and maintained properly, including dust buildup, overflowing garbage, debris, and brown buildup. |
| Facility failed to ensure MDS was coded to indicate residents had serious mental illness for Residents #25 and #67. |
| Clinical record for Resident #78 was incomplete, failing to document discharge against medical advice and related notifications. |
Report Facts
Licensed Bed Capacity: 96
Census: 81
Inspection Dates: 4
Audit Frequency: 3
Audit Duration: 60
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Krista Wagner | Administrator | Named in relation to interviews and findings regarding resident council concerns and facility operations. |
| Sandra Vermont-Hollis | Supervising Nurse Consultant | Author of the notice letter regarding plan of correction submission. |
| Housekeeper #1 | Interviewed regarding cleaning tasks and deficiencies in housekeeping. | |
| Director of Recreation | Interviewed regarding weekend activities and resident council concerns. | |
| Director of Housekeeping | Interviewed regarding cleaning responsibilities and audit plans. | |
| Social Worker (SW #1) | Interviewed regarding coding of MDS assessments for residents with mental illness. | |
| Director of Nursing (DNS) | Interviewed regarding documentation of clinical records. | |
| APRN #1 | Interviewed regarding clinical documentation and discharge against medical advice. | |
| Director of Maintenance | Interviewed regarding maintenance and cleaning of light fixtures. |
Inspection Report
Abbreviated Survey
Census: 72
Capacity: 90
Deficiencies: 0
Aug 12, 2020
Visit Reason
A COVID-19 Focused Survey was conducted to determine compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities, including proper infection prevention and control practices to prevent the development and transmission of COVID-19.
Findings
No deficiencies were cited as a result of this COVID-19 Focused Infection Control Survey.
Inspection Report
Abbreviated Survey
Census: 70
Capacity: 90
Deficiencies: 0
Jul 21, 2020
Visit Reason
A COVID-19 Focused Survey was conducted to determine compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities, including proper infection prevention and control practices to prevent the development and transmission of COVID-19.
Findings
The COVID-19 Focused Infection Control Survey found the facility compliant with no deficiencies cited related to infection prevention and control practices.
Report Facts
Capacity: 90
Census: 70
Inspection Report
Routine
Census: 74
Capacity: 90
Deficiencies: 0
Jul 8, 2020
Visit Reason
A COVID-19 Focused Survey was conducted to determine compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities, including proper infection prevention and control practices to prevent the development and transmission of COVID-19.
Findings
The COVID-19 Focused Infection Control Survey found the facility compliant with no deficiencies cited related to infection prevention and control practices.
Report Facts
Capacity: 90
Census: 74
Inspection Report
Routine
Census: 74
Capacity: 90
Deficiencies: 0
Jun 19, 2020
Visit Reason
A COVID-19 Focused Survey was conducted to determine compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities, including proper infection prevention and control practices to prevent the development and transmission of COVID-19.
Findings
No deficiencies were cited as a result of this COVID-19 focused survey.
Inspection Report
Abbreviated Survey
Census: 73
Capacity: 90
Deficiencies: 0
May 28, 2020
Visit Reason
A COVID-19 Focused Survey was conducted to determine compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities, including proper infection prevention and control practices to prevent the development and transmission of COVID-19.
Findings
The survey found no deficiencies related to infection prevention and control practices for COVID-19 at Autumn Lake Healthcare at Bucks Hill.
Inspection Report
Routine
Census: 64
Capacity: 90
Deficiencies: 0
May 19, 2020
Visit Reason
A COVID-19 Focused Survey was conducted to determine compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities, including proper infection prevention and control practices to prevent the development and transmission of COVID-19.
Findings
No deficiencies were cited as a result of this COVID-19 focused survey.
Report Facts
Capacity: 90
Census: 64
Inspection Report
Abbreviated Survey
Deficiencies: 0
Apr 28, 2020
Visit Reason
A COVID-19 Focused Survey was conducted to determine compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities, including proper infection prevention and control practices to prevent the development and transmission of COVID-19.
Findings
No deficiencies were cited as a result of this COVID-19 focused survey conducted at Autumn Lake Health Care at Bucks Hill.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Apr 23, 2020
Visit Reason
A COVID-19 Focused Survey was conducted to determine compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities, including proper infection prevention and control practices to prevent the development and transmission of COVID-19.
Findings
No deficiencies were cited as a result of this COVID-19 focused survey conducted on April 23, 2020.
Inspection Report
Plan of Correction
Deficiencies: 5
Nov 15, 2019
Visit Reason
Unannounced visits were made to Autumn Lake Healthcare At Bucks Hill for the purpose of conducting a survey and investigations, with additional information received through November 15, 2019. The document is an amended plan of correction letter responding to violations noted during these visits.
Findings
The facility was found noncompliant with several regulations including failure to conduct thorough investigations of abuse allegations, failure to follow resident care plans regarding lap tray removal during meals, failure to offer/administer pneumococcal vaccines according to CDC guidelines, failure to accurately code and timely report reportable events, and failure to ensure electrical outlets were secured. The plan of correction outlines measures to address these deficiencies.
Deficiencies (5)
| Description |
|---|
| Failure to conduct a thorough investigation prior to determining an allegation of abuse to be unsubstantiated. |
| Failure to follow the Resident Care Plan regarding removal of a left half lap tray during meals. |
| Failure to offer/administer pneumococcal vaccine according to CDC guidelines. |
| Failure to ensure accurate coding and timely reporting of a Reportable Event to the State Agency. |
| Failure to ensure a wall outlet was secured in a resident room. |
Report Facts
Plan of Correction submission deadline: Feb 3, 2020
Plan of Correction submission deadline: Dec 7, 2019
Resident sample sizes: 9
Resident sample sizes: 8
Resident sample sizes: 3
Audit frequency: 90
Audit frequency: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jason Mervin | Administrator | Named as responsible for oversight and task completion in plan of correction. |
| Jacqueline Ruot | Supervising Nurse Consultant | Signed letter regarding plan of correction instructions. |
| Judy Birtwistle | Supervising Nurse Consultant | Signed letter regarding complaint and plan of correction. |
Inspection Report
Complaint Investigation
Census: 79
Capacity: 90
Deficiencies: 5
Nov 12, 2019
Visit Reason
The inspection was conducted as a complaint investigation related to complaint numbers CT#25288 and T#24596, involving allegations of mistreatment and other regulatory violations at Autumn Lake Healthcare At Bucks Hill.
Findings
The investigation found multiple violations including failure to conduct thorough abuse investigations, failure to follow resident care plans, failure to administer pneumococcal vaccines per CDC guidelines, failure to report and classify reportable events accurately, and electrical safety hazards. Several deficiencies were substantiated and plans of correction were required.
Complaint Details
Complaint investigation #25288 and #24596 involved allegations of mistreatment of Resident #225. The facility concluded the allegation as 'unfounded' without interviewing all relevant staff. The investigation found the facility failed to conduct a thorough investigation prior to determining the allegation to be unsubstantiated.
Deficiencies (5)
| Description |
|---|
| Failure to conduct a thorough investigation of alleged abuse involving Resident #225, resulting in an unsubstantiated allegation without proper staff interviews. |
| Failure to follow Resident Care Plan regarding removal of left half lap tray during meals for Resident #55. |
| Failure to offer/administer pneumococcal vaccine according to CDC guidelines for Residents #4, #18, #34, and #37. |
| Failure to ensure accurate coding and timely reporting of a Reportable Event involving Resident #36, including misclassification of injury severity. |
| Electrical safety hazard due to detached and hanging electrical outlet and cover in Room #38. |
Report Facts
Licensed Bed Capacity: 90
Census: 79
Inspection Dates: Inspection conducted on 11/12, 11/13, 11/14, and 11/15 of 2019.
Plan of Correction Submission Deadline: Plan of correction to be submitted by December 7, 2019 and February 3, 2020 for different violations.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jason Mervin | Administrator | Named as facility administrator involved in the inspection and findings. |
| Ed Hawkins | Director of Nursing Services (DNS) | Named as DNS involved in the investigation and findings. |
| Judy Birtwistle | Supervising Nurse Consultant | Signed the report and involved in complaint investigation. |
| Jacqueline Ruot | Supervising Nurse Consultant | Signed the amended violation letter. |
Report
Dec 6, 2024
File
health-inspection_2024-12-06.pdf
Report
May 15, 2024
File
complaint-inspection_2024-05-15.pdf
Report
Nov 15, 2023
File
complaint-inspection_2023-11-15.pdf
Report
Aug 22, 2022
File
health-inspection_2022-08-22.pdf
Report
Nov 15, 2019
File
health-inspection_2019-11-15.pdf
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