Deficiencies (last 6 years)
Deficiencies (over 6 years)
10.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
82% worse than Connecticut average
Connecticut average: 5.6 deficiencies/yearDeficiencies per year
28
21
14
7
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.
Occupancy over time
Inspection Report
Renewal
Census: 85
Capacity: 90
Deficiencies: 0
Date: 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
Date: 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
Date: 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.
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.
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.
Deficiencies (12)
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
Annual Inspection
Deficiencies: 12
Date: Dec 6, 2024
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements for nursing home care and facility operations.
Findings
The facility was found deficient in multiple areas including failure to ensure signed advance directives, timely reporting of lost resident property, prevention of decline in residents' functional abilities, appropriate treatment and follow-up care, pressure ulcer care, maintenance of residents' hygiene, nutrition and hydration monitoring, food safety and sanitation, infection control practices, and environmental safety and cleanliness.
Deficiencies (12)
Failed to ensure advance directives consent was signed and available for Resident #329.
Failed to timely report loss of Resident #27's personal property 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 nephrology 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 weigh Resident #44 monthly, reweigh after weight loss, and ensure dietician re-evaluation; failed to complete and document weights for newly admitted Resident #281.
Failed to ensure food was served at safe and appetizing temperatures.
Failed to maintain dishwasher temperatures according to manufacturer's requirements for adequate sanitization.
Failed to ensure appropriate PPE use during high contact care for residents on Enhanced Barrier Precautions (Residents #41 and #59).
Failed to provide a homelike, sanitary, and safe environment in the [NAME] Unit tub room with cracked tiles, stained radiators, broken vanity cabinet, and dusty fan.
Report Facts
Weight loss: 6.6
Weight: 103.8
Weight: 97.2
Weight: 97.9
Weight: 120
Weight: 135
Weight: 114.2
Dishwasher wash temperature: 145
Dishwasher rinse temperature: 160
Food temperature: 118
Food temperature: 119.4
Food temperature: 111
Food temperature: 46
Employees mentioned
| Name | Title | Context |
|---|---|---|
| APRN #1 | Advanced Practice Registered Nurse | Named in findings related to Resident #329 advance directives and Resident #5 nephrology follow-up |
| Director of Nurses | Director of Nursing Services | Interviewed regarding multiple deficiencies including advance directives, pressure ulcer care, and splint application |
| NA #3 | Nurse Aide | Named in findings related to Resident #44 ambulation decline, Resident #22 nail care and splint application, and weight monitoring |
| LPN #2 | Licensed Practical Nurse | Named in findings related to Resident #44 ambulation decline and pressure ulcer care |
| PT #1 | Physical Therapist | Named in findings related to Resident #44 ambulation decline and splint application |
| NA #1 | Nurse Aide | Named in infection control deficiency for Resident #59 |
| NA #2 | Nurse Aide | Named in infection control deficiency for Resident #41 |
| Director of Food Services | Named in dishwasher sanitization deficiency | |
| Dietician | Named in nutrition and weight monitoring deficiencies | |
| Administrator | Interviewed regarding facility environment and advance directives | |
| Maintenance Director | Interviewed regarding facility environment deficiencies |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: May 15, 2024
Visit Reason
The inspection was conducted to investigate complaints regarding the facility's failure to ensure timely scheduling of a follow-up specialist appointment for Resident #2 after admission and failure to ensure timely notification to the dialysis center of physician orders for medication administration.
Complaint Details
The investigation was complaint-related, focusing on Resident #2's quality of care issues including missed follow-up appointments and missed medication doses at dialysis. The report indicates the complaint was substantiated with findings of deficiencies.
Findings
The facility failed to schedule a timely follow-up appointment with an orthopedic specialist for Resident #2 and failed to notify the dialysis center of Vancomycin orders, resulting in Resident #2 missing nine doses of the medication during dialysis. The facility lacked policies for scheduling appointments and for notifying dialysis of medication orders.
Deficiencies (2)
Failure to ensure a follow-up specialist appointment was scheduled timely after a new admission.
Failure to ensure timely notification to the dialysis center of physician orders for medication administration, resulting in missed doses of Vancomycin.
Report Facts
Missed Vancomycin doses: 9
Vancomycin administration frequency: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN Supervisor | Identified as responsible for ensuring appointments and transport scheduling. | |
| Administrator | Interviewed regarding scheduling errors and responsibility for follow-up appointments. | |
| DON | Director of Nursing | Interviewed about communication failures and medication order notification issues. |
| RN #2 | Dialysis RN | Interviewed about missed Vancomycin administration and lack of notification. |
| RN #3 | Wrote nursing note documenting communication with MD #1's office regarding labs. |
Inspection Report
Follow-Up
Census: 84
Capacity: 90
Deficiencies: 0
Date: 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
Deficiencies: 5
Date: Nov 15, 2023
Visit Reason
The inspection was conducted based on complaints regarding failure to notify the Power of Attorney of a resident's change in condition, failure to conduct and document wound assessments and weekly skin assessments, and failure to follow physician's orders for laboratory blood work.
Complaint Details
The visit was complaint-related, focusing on failure to notify the Power of Attorney, failure to conduct wound and skin assessments, and failure to obtain ordered laboratory blood work. The complaint was substantiated based on clinical record reviews and interviews.
Findings
The facility failed to notify the Power of Attorney when Resident #1 experienced changes in condition and new treatment orders, failed to conduct and document initial wound assessments and weekly skin assessments as ordered, and failed to obtain ordered laboratory blood work on a specified date. These deficiencies were identified through clinical record reviews, facility documentation, policies, and interviews.
Deficiencies (5)
Failure to notify the Power of Attorney at the time Resident #1 experienced a change in condition and new medication and laboratory orders.
Failure to conduct and document an initial wound assessment when blisters were identified on Resident #1.
Failure to conduct and document weekly skin assessments in accordance with the physician's order for Resident #1.
Failure to follow the physician's order and obtain laboratory blood work ordered for Resident #1 on 9/3/23.
Failure to timely verify and document consulting physician/practitioner orders as per facility policy.
Report Facts
Dates of missed weekly skin assessments: 7/25, 8/1, 8/8, 8/22, 8/29, 9/5, and 9/12/23
Medication order frequency: 4
Intravenous fluid order: 75
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #1 | 7AM-3PM Nursing Supervisor | Identified failure to notify Power of Attorney and failure to conduct weekly skin assessments |
| Licensed Practical Nurse #1 | Wound Nurse | Interviewed regarding failure to assess and measure new skin impairment |
| Administrator | Interviewed regarding missing laboratory blood work |
Inspection Report
Complaint Investigation
Census: 84
Capacity: 90
Deficiencies: 5
Date: Nov 15, 2023
Visit Reason
The inspection was conducted as a complaint investigation related to Complaint #36395 at Autumn Lake Healthcare at Bucks Hill.
Complaint Details
Complaint #36395 triggered the inspection. The complaint was substantiated with findings of noncompliance in multiple areas including resident care and staffing.
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.
Deficiencies (5)
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
Date: 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.
Complaint Details
Complaint #36395 was investigated. Violations were substantiated as the facility failed to comply with regulations regarding resident care and documentation.
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.
Deficiencies (4)
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
Annual Inspection
Deficiencies: 4
Date: Aug 22, 2022
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements related to resident rights, housekeeping, resident assessments, and clinical record maintenance.
Findings
The facility was found deficient in responding to resident council concerns about weekend activities, maintaining cleanliness and housekeeping standards, accurately coding residents' serious mental illness status in assessments, and documenting discharge against medical advice properly. Deficiencies were noted with minimal harm or potential for actual harm affecting some or few residents.
Deficiencies (4)
Failed to respond to resident council concerns regarding varied weekend activities and availability of recreation materials.
Housekeeping failed to maintain cleanliness in resident rooms and shower areas, including dust buildup, debris, and unemptied garbage.
Failed to ensure the MDS was coded to indicate residents had a serious mental illness for two sampled residents.
Failed to ensure the clinical record was complete for a resident discharged against medical advice, including lack of documentation of notification to physician and APRN.
Report Facts
Residents affected: Some or few residents affected as stated in deficiencies
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Housekeeper #1 | Responsible for cleaning resident rooms and shower room; identified as not completing all required daily tasks. | |
| Director of Recreation | Aware of resident council concerns about weekend activities and difficulty with weekend recreation staff. | |
| Administrator | Acknowledged resident council request for weekend activity cart. | |
| Social Worker (SW #1) | Social Worker | Responsible for coding MDS assessments; admitted oversight in coding serious mental illness. |
| Director of Housekeeping | Identified daily cleaning responsibilities and confirmed housekeeping was not short staffed on 8/18/22. | |
| Director of Maintenance | Responsible for cleaning debris in light fixtures; acknowledged delay due to workload. | |
| DNS | Director of Nursing Services | Identified nurses should have documented discharge against medical advice in clinical record. |
| APRN #1 | Advanced Practice Registered Nurse | On call during discharge against medical advice; vaguely recalled related call. |
Inspection Report
Renewal
Census: 81
Capacity: 96
Deficiencies: 4
Date: 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)
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
Date: 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
Date: 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
Date: 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
Date: 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
Date: 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
Date: 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
Date: 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
Date: 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
Complaint Investigation
Deficiencies: 3
Date: Nov 15, 2019
Visit Reason
The inspection was conducted following an allegation of abuse involving Resident #225 and a complaint regarding failure to follow the Resident Care Plan for Resident #55, as well as concerns about pneumococcal immunization practices.
Complaint Details
The complaint involved an allegation of abuse where Resident #225 reported being tapped on the forehead with a hairbrush to wake them up. The facility only interviewed the resident and did not interview other staff or witnesses before concluding the allegation unsubstantiated. The Director of Nursing Services deemed the allegation unfounded based on the resident's denial during interview and cognitive status, despite policy requiring broader investigation.
Findings
The facility failed to conduct a thorough investigation of an abuse allegation for Resident #225, concluding it was unsubstantiated without interviewing all relevant parties. The facility also failed to follow the care plan for Resident #55 regarding removal of a half lap tray during meals, causing discomfort. Additionally, the facility did not offer pneumococcal vaccines according to CDC guidelines for several residents.
Deficiencies (3)
Failed to conduct a thorough investigation of an abuse allegation for Resident #225 prior to determining it unsubstantiated.
Failed to follow Resident Care Plan for Resident #55 by not removing the half lap tray during meals as ordered.
Failed to offer/administer pneumococcal vaccines according to CDC guidelines for 4 of 8 sampled residents.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Person #5 | Reported abuse allegation and was not interviewed by facility | |
| Director of Nursing Services (DNS) | Director of Nursing Services | Deemed abuse allegation unsubstantiated without full investigation |
| Nurse Aide #3 | Nurse Aide | Unaware of half lap tray removal requirement during meals |
| Licensed Practical Nurse (LPN) #3 | Licensed Practical Nurse | Confirmed lack of physician order documentation for half lap tray removal |
| Occupational Therapist (OTR) #1 | Occupational Therapist | Recommended half lap tray removal for Resident #55 for comfort and feeding |
| Infection Control Nurse (ICN) | Infection Control Nurse | Acknowledged failure to track pneumococcal vaccine due dates for long-term residents |
Inspection Report
Plan of Correction
Deficiencies: 5
Date: 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)
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
Date: 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.
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.
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.
Deficiencies (5)
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. |
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