Inspection Report Summary
The most recent inspection on September 17, 2025, found no deficiencies during a complaint investigation. Earlier inspections generally showed a pattern of no violations, with multiple complaint investigations in 2024 and 2025 also substantiating no deficiencies. Prior to that, the facility had citations mainly related to resident care documentation, infection control, and environmental safety issues, particularly during 2019 and 2020, including deficiencies in fall risk management, pressure ulcer care, and COVID-19 protocols. Complaint investigations were mostly unsubstantiated in recent years, with one substantiated Class A occurrence related to reporting an attempted suicide in 2019. The inspection history indicates improvement over time, with no deficiencies noted in the most recent reports after earlier periods of cited issues.
Deficiencies (last 6 years)
Deficiencies (over 6 years)
7.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
39% worse than Connecticut average
Connecticut average: 5.6 deficiencies/year
Deficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
96% occupied
Based on a September 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 168
Capacity: 175
Deficiencies: 0
Sep 17, 2025
Visit Reason
The inspection visit was conducted as a complaint investigation related to Complaint Investigations #2599442.
Findings
No 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 Investigations #2599442 was the basis for the visit; no violations were substantiated.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Chaim Scher | Administrator | Personnel contacted during the inspection. |
| Tanya Hopkins | Director of Nursing | Personnel contacted during the inspection. |
| Deborah Smith | RN, NC | Report submitted by. |
Inspection Report
Complaint Investigation
Census: 169
Capacity: 175
Deficiencies: 0
May 9, 2025
Visit Reason
The inspection visit was conducted as a complaint investigation related to Complaint Investigations #41412 and #44118.
Findings
No violations of the General Statutes of Connecticut and/or regulations of Connecticut State Agencies were identified at the time of this inspection.
Complaint Details
The visit was complaint-related, investigating Complaint Investigations #41412 and #44118. No violations were substantiated.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Chaim Scher | Administrator | Personnel contacted during the inspection |
| Tanya Hopkins | DON | Personnel contacted during the inspection |
Inspection Report
Complaint Investigation
Census: 161
Capacity: 175
Deficiencies: 0
Jan 31, 2025
Visit Reason
The inspection visit was conducted as a complaint investigation identified by Complaint Investigation #42608.
Findings
No 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 #42608 was the basis for the visit. The complaint was not substantiated as no violations were found.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michelle Morrison | Regional Nurse | Personnel contacted during the inspection. |
| Connie Vumback | RN | Report submitted by. |
Inspection Report
Renewal
Census: 160
Capacity: 174
Deficiencies: 0
Jul 29, 2024
Visit Reason
The inspection was conducted as a licensing renewal inspection and included review of complaint investigations numbered 31416, 33711, 34813, and 37961.
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 investigations referenced by numbers 31416, 33711, 34813, and 37961 were reviewed during the inspection.
Report Facts
Licensed Bed Capacity: 174
Census: 160
Inspection Report
Complaint Investigation
Census: 163
Capacity: 175
Deficiencies: 0
Feb 20, 2024
Visit Reason
The inspection visit was conducted as a complaint investigation identified by complaint number #37377.
Findings
No violations of the General Statutes of Connecticut and/or the regulations of Connecticut State Agencies were identified at the time of this inspection.
Complaint Details
Complaint investigation #37377 was conducted and found no violations; the complaint was not substantiated.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Chaim Scher | Administrator | Personnel contacted during the inspection. |
| Tanya Hopkins | DNS | Personnel contacted during the inspection. |
| Monika Ahlers | ADON | Personnel contacted during the inspection. |
| Deborah Smith | RN, NC | Report submitted by. |
Inspection Report
Complaint Investigation
Census: 159
Capacity: 175
Deficiencies: 0
Jan 25, 2024
Visit Reason
The inspection visit was conducted as a complaint investigation related to Complaint Investigation #37061.
Findings
No 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 #37061 was the basis for the visit. Violations were not identified at the time of this inspection.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Chaim Scher | Administrator | Personnel contacted during the inspection. |
| Tanya Hopkins | DNS | Personnel contacted during the inspection. |
| Monika Ahlers | ADON | Personnel contacted during the inspection. |
| Deborah Smith | RN, NC | Signature of FLIS Staff and report submitter. |
Inspection Report
Complaint Investigation
Census: 162
Capacity: 175
Deficiencies: 0
Dec 27, 2022
Visit Reason
The inspection visit was conducted as a complaint investigation related to Complaint Investigation # CT 00033230.
Findings
No 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 # CT 00033230 was reviewed and no violations were substantiated.
Report Facts
Licensed Bed/Bassinet Capacity: 175
Census: 162
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Chaim Scher | Administrator | Personnel contacted during inspection |
| Tanya Hopkins | DNS | Personnel contacted during inspection |
Inspection Report
Renewal
Census: 132
Capacity: 175
Deficiencies: 0
Apr 15, 2022
Visit Reason
The inspection was conducted as a renewal licensing inspection for the facility.
Findings
The report indicates that this was a renewal inspection with no explicit violations or deficiencies noted in the provided page.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Chaim Scher | Administrator | Personnel contacted during the inspection. |
| Tonya Hopkins | DNS | Personnel contacted during the inspection. |
Inspection Report
Renewal
Census: 132
Capacity: 175
Deficiencies: 0
Apr 8, 2022
Visit Reason
The inspection was conducted as a renewal licensure inspection for the facility.
Findings
No violations or citations were indicated on the report. The document does not specify any deficiencies or violations found during the inspection.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tonya Hopkins | DNS | Personnel contacted during the inspection. |
| Chaim Scher | Administrator | Personnel contacted during the inspection. |
Inspection Report
Renewal
Census: 132
Capacity: 175
Deficiencies: 0
Apr 8, 2022
Visit Reason
The inspection was conducted as a renewal licensing inspection for the facility.
Findings
No specific violations or deficiencies are indicated on the form. The report appears to document the completion of the renewal inspection process.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Chain Scher | Administrator | Personnel contacted during the inspection |
| Tonya Hopkins | DNS | Personnel contacted during the inspection |
Inspection Report
Plan of Correction
Census: 109
Capacity: 175
Deficiencies: 7
Oct 29, 2020
Visit Reason
Unannounced visits were made to Autumn Lake Healthcare At Cromwell to conduct multiple investigations and an inspection related to complaints and COVID-19 infection control.
Findings
The facility was found noncompliant with multiple regulations including fall risk management, pressure ulcer care, resident safety, weight loss monitoring, medical record accuracy, infection control practices, and COVID-19 outbreak testing. Several deficiencies were identified related to delayed interventions, incomplete documentation, unsafe environment, and inadequate infection control measures.
Complaint Details
Complaint numbers CT28504, CT28572, CT28723 were investigated. The allegations included falls, pressure ulcers, abuse, weight loss, medical record inaccuracies, infection control deficiencies, and COVID-19 outbreak testing failures. Some allegations were not substantiated as noted in the investigation.
Deficiencies (7)
| Description |
|---|
| Failure to implement timely interventions after a resident fall and inadequate monitoring. |
| Failure to ensure pressure relieving devices were placed timely and pressure ulcers were properly measured and documented. |
| Failure to maintain a safe resident environment, including unsecured staff breakroom and unsafe hot coffee pot. |
| Failure to monitor and document resident fluid status and weight loss accurately and completely. |
| Failure to ensure medical records were accurate and complete, including weight documentation and change in condition notifications. |
| Failure to implement appropriate infection control practices, including improper mask use and failure to follow CDC guidance. |
| Failure to ensure weekly COVID-19 testing was conducted after outbreak identification. |
Report Facts
Licensed Bed Capacity: 175
Census: 109
Completion Date: Dec 7, 2020
Weight Loss: 5.6
Weight Loss Percentage: 13
Pressure Ulcer Measurement: 3
Pressure Ulcer Depth: 0.1
Pressure Ulcer Depth: 0.7
Pressure Ulcer Length: 1
Pressure Ulcer Width: 1
Fluid Intake: 800
Weight: 176.8
Weight: 171.2
Weight: 156.4
Temperature: 102
Coffee Pot Temperature: 160
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Cher Michaud | Supervising Nurse Consultant | Named in complaint investigation and correspondence |
| Ana McBrat | Director of Nursing (DNS) | Interviewed regarding fall and pressure ulcer findings |
| Lisa Walles | Infection Control Nurse (ICN) | Interviewed regarding COVID-19 outbreak testing and infection control |
| Sandra Vermont-Hollis | Supervising Nurse Consultant | Signed notice of noncompliance letter |
Inspection Report
Complaint Investigation
Deficiencies: 6
Oct 29, 2020
Visit Reason
Unannounced visits were made to Autumn Lake Healthcare At Cromwell on October 29, 2020, by a representative of the Facility Licensing and Investigations Section of the Department of Public Health for the purpose of conducting multiple investigations and an inspection related to complaints.
Findings
The facility was found deficient in multiple areas including failure to prevent falls, timely pressure ulcer care, ensuring a safe environment free from abuse, monitoring resident fluid status, maintaining accurate medical records, implementing infection control practices, and conducting weekly COVID-19 testing after an outbreak was identified.
Complaint Details
The visit was complaint-related with complaints #CT28504, CT28572, CT28723. The investigation included review of incidents involving falls, pressure ulcers, abuse allegations, weight loss, infection control, and COVID-19 outbreak testing.
Deficiencies (6)
| Description |
|---|
| Failure to implement timely interventions after a resident fall and inadequate monitoring post-fall. |
| Failure to ensure pressure relieving devices were placed timely and pressure ulcers were properly measured and documented. |
| Failure to ensure the resident environment was free from safety hazards related to staff breakroom access and maintenance of coffee pot safety. |
| Failure to monitor and document resident fluid status adequately, leading to poor fluid intake monitoring. |
| Failure to maintain accurate and complete medical records including weight documentation and change in condition notifications. |
| Failure to implement appropriate infection control practices including mask wearing and COVID-19 testing protocols. |
Report Facts
Completion Date for Plan of Correction: Dec 7, 2020
Weight loss percentage: 13
Pressure ulcer blister measurement: 3
Weight loss in pounds: 5.6
Temperature: 102
Coffee pot temperature: 160
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Cher Michaud | Supervising Nurse Consultant | Signed the notice letter and involved in the Facility Licensing and Investigations Section. |
| Director of Nurses | Interviewed multiple times regarding findings related to falls, pressure ulcers, weight loss, and infection control. | |
| Advanced Practice Registered Nurse | Conducted assessments and gave orders related to pressure ulcers and weight loss. | |
| Licensed Practical Nurse #1 | Interviewed regarding resident abuse incident and staff breakroom access. | |
| Maintenance Director | Interviewed regarding safety check of coffee pot in staff breakroom. | |
| Infection Control Nurse | Interviewed regarding infection control practices and COVID-19 testing. | |
| Dietary Aide #1 | Observed with mask hanging off ear and interviewed about mask use in kitchen. | |
| Therapeutic Recreation Director | Interviewed regarding mask use during activity. | |
| Nurse Aide #1 | Observed speaking to unmasked resident and interviewed about mask use. | |
| Employee #1 | Had a temperature of 102 degrees and tested positive for COVID-19. |
Inspection Report
Complaint Investigation
Census: 118
Capacity: 175
Deficiencies: 2
Oct 2, 2020
Visit Reason
A COVID-19 Focused Survey and complaint investigation were conducted to determine compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities, including infection prevention and control practices to prevent COVID-19 transmission.
Findings
The facility was found deficient in maintaining accurate and complete medical records for one resident, failing to notify the responsible party of medication changes, and improper documentation of diet orders. Additionally, a staff member failed to wear a surgical mask properly while providing care, posing an infection control risk.
Complaint Details
The visit was complaint-related, triggered by concerns about infection control and medical record accuracy. The complaint was substantiated as deficiencies were identified.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure medical record was accurate and complete for Resident #1, including lack of notification to responsible party about medication changes and incomplete documentation of events prior to resident's death. | SS=D |
| Failure to maintain proper infection prevention and control practices by not wearing a surgical mask at all times while providing care to Resident #2. | SS=D |
Report Facts
Medication administrations: 7
Facility capacity: 175
Resident census: 118
Mask falls: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #2 | LPN | Named in medication notification deficiency for Resident #1. |
| Licensed Practical Nurse #1 | LPN | Charge nurse on duty when Resident #1 passed away; involved in documentation deficiency. |
| Nurse Aide #1 | NA | Failed to wear surgical mask properly while providing care to Resident #2. |
| Director of Nurses | DNS | Provided statements regarding documentation and infection control deficiencies. |
| Assistant Director of Nurses | ADNS | Observed mask non-compliance and directed corrective action. |
Inspection Report
Abbreviated Survey
Census: 105
Capacity: 175
Deficiencies: 0
May 24, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted to determine compliance with 42 CFR §483.80 Infection Control regulations for Long Term Care Facilities.
Findings
The facility implemented CMS and CDC recommended practices related to COVID-19. No deficiencies were cited as a result of this survey.
Report Facts
Capacity: 175
Census: 105
Inspection Report
Complaint Investigation
Deficiencies: 0
May 6, 2020
Visit Reason
A COVID-19 Focused Survey and a complaint investigation were 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 survey.
Complaint Details
The visit was complaint-related and included a COVID-19 focused survey; no deficiencies were found.
Inspection Report
Monitoring
Deficiencies: 6
Apr 28, 2020
Visit Reason
An unannounced visit was conducted on April 28, 2020, by a representative of the Facility Licensing and Investigations Section of the Department of Public Health to investigate and monitor COVID-19 infection control practices at Autumn Lake Healthcare At Cromwell.
Findings
The facility failed to ensure acceptable infection control practices, including improper use and storage of N95 masks, failure to provide masks to residents, lack of door closures on rooms with COVID-19 positive residents, and inadequate social distancing measures. Several observations and interviews identified multiple infection control deficiencies related to mask usage, resident placement, and gown and face shield handling.
Deficiencies (6)
| Description |
|---|
| Director of Nurses donned an N95 mask on top of a surgical mask. |
| Residents on contact precautions were exposed without masks and doors were not closed as recommended. |
| Staff members wore surgical masks under N95 masks; one staff member identified as CNA. |
| Facility failed to provide masks to residents on the secured unit and did not enforce social distancing. |
| Face masks were stored improperly on gowns causing contamination risk. |
| Facility did not store gowns and face shields according to CDC guidance and did not don N95 masks or post information as per CDC guidelines. |
Report Facts
Date of visit: Apr 28, 2020
Number of residents observed without masks: 6
Number of residents in contact precautions: 2
Number of staff members observed wearing surgical masks under N95 masks: 4
Number of additional residents' rooms with contact precautions and doors not closed: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sandra Vermont-Hollis | Supervising Nurse Consultant | Signed letter as Supervising Nurse Consultant for Facility Licensing and Investigations Section |
| Jessica Garcia | Administrator | Administrator of Autumn Lake Healthcare At Cromwell addressed in the letter |
Inspection Report
Abbreviated Survey
Deficiencies: 5
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
The facility failed to ensure acceptable infection control practices including improper donning of N95 masks, inadequate masking and social distancing among residents, improper storage and reuse of gowns and face shields, and failure to follow CDC guidance on infection prevention measures.
Severity Breakdown
SS=E: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Acting Director of Nurses donned an N95 mask on top of a surgical mask, contrary to CDC guidance. | SS=E |
| Residents on contact precautions were not properly masked or isolated; curtains were not fully drawn and residents ambulated without masks. | SS=E |
| Staff wore surgical masks under N95 masks, and signage posted did not comply with infection control standards. | SS=E |
| Residents on the secured dementia unit were not offered masks and did not maintain social distancing. | SS=E |
| Gowns and face shields on the COVID unit were improperly stored, causing contamination and cross contamination risks. | SS=E |
Report Facts
Date of survey: Apr 28, 2020
Number of gowns observed: 6
Audit frequency: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Acting Director of Nurses | Donning N95 mask improperly | |
| LPN #1 | Licensed Practical Nurse | Did not offer masks to dementia unit residents |
| LPN #2 | Licensed Practical Nurse | Described gown and face shield storage and use |
| Infection Preventionist | Identified contamination risks with gown and face shield storage and improper masking | |
| DNS | Director of Nursing Services | Interviewed about resident masking and social distancing |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Apr 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
No deficiencies were cited as a result of this COVID-19 focused survey.
Inspection Report
Complaint Investigation
Census: 130
Capacity: 175
Deficiencies: 7
Jul 25, 2019
Visit Reason
The inspection was conducted as a complaint investigation triggered by Complaint Investigation #25285 to assess violations of Connecticut General Statutes and regulations.
Findings
The facility was found to have violations related to failure in ensuring complete hospital information during urgent resident transfers, inadequate communication with hospitals, and deficiencies in resident care and safety measures. A plan of correction was required to address these issues.
Complaint Details
Complaint Investigation #25285 was substantiated with violations identified related to resident transfer communication and care deficiencies.
Deficiencies (7)
| Description |
|---|
| Failure to ensure hospital received complete information when resident was urgently transferred. |
| Facility failed to maintain a clean, well-maintained, and homelike environment on the 2nd floor Maple unit. |
| Facility failed to maintain the dietary/kitchen area in a sanitary manner. |
| Facility failed to ensure a water management plan was in place to reduce Legionella risk. |
| Facility failed to ensure skilled competencies for nurse aides regarding intravenous therapy. |
| Facility failed to ensure care was rendered to ensure privacy for residents. |
| Facility failed to maintain the kitchen/dietary area free from rodents. |
Report Facts
Licensed Bed Capacity: 175
Census: 130
Complaint Number: 25285
Plan of Correction Submission Deadline: Aug 15, 2019
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Chaim Scheer | Administrator | Named in relation to findings about resident transfer communication. |
| Gina Jones-Blue | Director of Nursing (DON) | Named in relation to findings about resident transfer communication. |
| Heidi Caron | Supervising Nurse Consultant | Signed complaint investigation letter. |
| Jessica Garcia | Administrator | Named in follow-up complaint investigation and related correspondence. |
| Judy Birtwistle | Supervising Nurse Consultant | Signed follow-up complaint investigation letter. |
| Kafaytou Afolabi | Director of Nursing Services (DNS) | Named in relation to inspection findings and interviews. |
Inspection Report
Plan of Correction
Deficiencies: 1
Jul 25, 2019
Visit Reason
An unannounced visit was conducted at Autumn Lake Healthcare At Cromwell on July 25, 2019, 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 July 25, 2019.
Findings
The facility failed to ensure that the hospital received complete and resident-specific hospital information when a resident was urgently transferred. Documentation and interviews revealed incomplete transfer information and lack of communication with the receiving hospital.
Complaint Details
Complaint #25785 triggered the investigation.
Deficiencies (1)
| Description |
|---|
| Failure to ensure hospital received complete hospital information when resident was urgently transferred, including lack of resident-specific details and failure to notify hospital appropriately. |
Report Facts
Complaint number: 25785
Date of visit: Jul 25, 2019
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Heidi Caron | Supervising Nurse Consultant | Signed letter regarding plan of correction and deficiencies |
| Jessica Garcia | Facility representative addressed in the letter |
Inspection Report
Plan of Correction
Deficiencies: 1
Jun 20, 2019
Visit Reason
An unannounced visit was made to Autumn Lake Healthcare At Cromwell on June 20, 2019 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 certification survey.
Findings
The facility was found to have a violation related to failure to ensure an attempted suicide was reported to the State Agency within mandated time frames and/or appropriately identified/classified as a Class A occurrence. The violation involved Resident #1 and included deficiencies in documentation and reporting.
Complaint Details
Complaint #25578 was investigated. The complaint involved failure to timely report and classify an attempted suicide of Resident #1. The violation was substantiated as a Class A occurrence.
Severity Breakdown
Class A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure an attempted suicide was reported to the State Agency within mandated time frames and/or appropriately identified/classified as a Class A occurrence. | Class A |
Report Facts
Complaint number: 25578
Dates related to Resident #1: Admission date 2019-04-10, PASRR dated 2019-03-27, MDS assessment dated 2019-04-14, Social Service note dated 2019-04-16
Plan of Correction completion date: July 11, 2019
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Judith Birtwistle | Supervising Nurse Consultant | Signed letter regarding complaint investigation and plan of correction |
Inspection Report
Annual Inspection
Deficiencies: 4
Jan 22, 2019
Visit Reason
Unannounced visits were made to the facility on 1/15/19, 1/16/19, 1/17/19 and 1/22/19 by representatives of the Facility Licensing & Investigations Section for the purpose of a certification survey, licensure inspection, and an investigation.
Findings
The facility was found to have multiple deficiencies including failure to maintain a safe, clean, comfortable, and homelike environment; unsanitary food procurement, storage, preparation and serving areas; improper disposal of garbage and refuse; and lack of a comprehensive water management plan to reduce Legionella risk. Numerous physical environment issues such as water stains, damaged fixtures, and unsanitary conditions in the kitchen and dumpster area were observed.
Severity Breakdown
SS=D: 1
SS=E: 2
SS=F: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Facility failed to maintain a clean, well-maintained and homelike environment with issues such as water stains, damaged bathroom fixtures, exposed sharp edges, and unsanitary resident nourishment room. | SS=D |
| Facility failed to maintain the dietary/kitchen area in a sanitary manner including uncovered food bins with debris, rodent droppings, open food containers, soiled equipment, and rodent sightings. | SS=E |
| Facility failed to properly dispose of garbage and refuse, with garbage debris and used gloves found around the exterior dumpster area. | SS=E |
| Facility failed to establish and maintain an infection prevention and control program including lack of a comprehensive water management plan to reduce Legionella risk. | SS=F |
Report Facts
Dates of unannounced visits: 1/15/19, 1/16/19, 1/17/19, 1/22/19
Weight of sugar bin: 40
Weight of flour bin: 25
Number of resident serving trays damaged: 100
Number of mouse traps observed: 6
Weight of thawing chicken: 20
Number of pocket books/handbags stored in nourishment room: 3
Number of lunch containers stored in nourishment room: 2
Number of soda cans stored in nourishment room: 0
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Food Service Director (FSD) | Interviewed regarding kitchen sanitation deficiencies and food safety | |
| Registered Nurse #1, Infection Control Nurse (ICN) | Interviewed regarding use of nourishment room as staff break room and infection control concerns | |
| Administrator | Interviewed regarding facility remodeling and water management plan deficiencies | |
| Maintenance Director | Interviewed regarding facility maintenance issues and water management plan deficiencies |
Inspection Report
Plan of Correction
Deficiencies: 8
Jan 15, 2019
Visit Reason
Unannounced visits were made to Autumn Lake Healthcare At Cromwell on January 15, 16, 17 and 22, 2019 by representatives of the Facility Licensing and Investigations Section of the Department of Public Health for the purpose of conducting an investigation, a licensure and a certification inspection.
Findings
The facility was found to have multiple violations including failure to maintain a clean, well-maintained, and homelike environment; unsanitary dietary/kitchen areas; failure to maintain the exterior dumpster area in a clean and sanitary manner; lack of a comprehensive water management plan to reduce Legionella risk; and failure to ensure skilled competencies for nurse aides regarding intravenous therapy. The facility submitted a plan of correction addressing these deficiencies.
Complaint Details
Complaint #23754 triggered the investigation and inspection.
Deficiencies (8)
| Description |
|---|
| Facility failed to maintain a clean, well-maintained and homelike environment with multiple damaged areas and water stains in resident rooms and common areas. |
| Dietary/kitchen area was not maintained in a sanitary manner with uncovered food bins, mouse/rodent droppings, and soiled surfaces. |
| Exterior dumpster area was not maintained in a clean and sanitary manner with garbage debris and used exam gloves strewn about. |
| Facility failed to ensure a water management plan was in place to reduce Legionella risk as required by regulations. |
| Facility failed to ensure skilled competencies were completed for nurse aides regarding intravenous therapy. |
| Facility failed to ensure care was rendered to ensure privacy for a resident during blood pressure monitoring. |
| Facility failed to maintain kitchen/dietary area free from rodents with excessive mouse traps and rodent droppings observed. |
| Facility failed to maintain a plan of care for pressure ulcer prevention for a resident at high risk. |
Report Facts
Weight of storage bins: 40
Weight of storage bins: 25
Mouse traps observed: 6
Thawing chicken weight: 20
Pest control service visits: 17
Nurse aides competency validated: 14
Plan of correction monitoring period: 90
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Connie Greene | Supervising Nurse Consultant | Signed the plan of correction letter and is the contact for questions regarding deficiencies. |
| Jessica Garcia | Administrator | Administrator of Autumn Lake Healthcare At Cromwell, involved in tours and interviews during inspection. |
| Registered Nurse #1 | Infection Control Nurse | Interviewed regarding infection control practices and unaware of staff using resident nourishment room as break room. |
| Food Service Director #1 | Food Service Director | Interviewed regarding kitchen sanitation and food storage deficiencies. |
| Maintenance Director | Interviewed regarding facility maintenance issues including bathtub water turned off and facility remodeling. | |
| Registered Nurse #1 | Interviewed regarding incident of privacy violation and intravenous therapy education. | |
| Nurse Aide #1 | Involved in privacy violation incident and education regarding intravenous therapy. | |
| Nurse Aide #2 | Involved in privacy violation incident and education regarding intravenous therapy. | |
| Licensed Practical Nurse #1 | Interviewed regarding care of resident with pressure ulcers. | |
| Administrator | Interviewed multiple times regarding facility conditions, remodeling, and infection control. |
Inspection Report
Renewal
Census: 117
Capacity: 170
Deficiencies: 0
Jan 19, 2018
Visit Reason
The inspection was conducted as a licensing inspection for renewal purposes, including a desk audit on 1/19/18.
Findings
No violations of the General Statutes of Connecticut or regulations were identified at the time of this inspection. The facility was found to be in substantial compliance.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jessica Garcia | Administrator | Personnel contacted during the inspection. |
| Melissa Dziob | Report submitted by. |
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