Deficiencies (last 7 years)
Deficiencies (over 7 years)
11 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
96% worse than Connecticut average
Connecticut average: 5.6 deficiencies/yearDeficiencies per year
28
21
14
7
0
Occupancy
Latest occupancy rate
96% occupied
Based on a September 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Complaint Investigation
Census: 168
Capacity: 175
Deficiencies: 0
Date: Sep 17, 2025
Visit Reason
The inspection visit was conducted as a complaint investigation related to Complaint Investigations #2599442.
Complaint Details
Complaint Investigations #2599442 was the basis for the visit; no violations were substantiated.
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
| 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
Date: May 9, 2025
Visit Reason
The inspection visit was conducted as a complaint investigation related to Complaint Investigations #41412 and #44118.
Complaint Details
The visit was complaint-related, investigating Complaint Investigations #41412 and #44118. No violations were substantiated.
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
| 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
Date: Jan 31, 2025
Visit Reason
The inspection visit was conducted as a complaint investigation identified by Complaint Investigation #42608.
Complaint Details
Complaint Investigation #42608 was the basis for the visit. The complaint was not substantiated as no violations were found.
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
| 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
Date: 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.
Complaint Details
Complaint investigations referenced by numbers 31416, 33711, 34813, and 37961 were reviewed during the inspection.
Findings
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: 174
Census: 160
Inspection Report
Routine
Deficiencies: 12
Date: Jul 25, 2024
Visit Reason
Routine inspection of Autumn Lake Healthcare at Cromwell to assess compliance with healthcare regulations including resident rights, environment, medication management, food service, infection control, and staffing.
Findings
The facility had multiple deficiencies including failure to address resident food committee concerns, environmental maintenance issues, failure to report resident-to-resident mistreatment to appropriate agencies, incomplete PASRR Level II referrals, delayed incontinent care, inadequate fluid intake monitoring, medication administration errors, improper medication storage, food temperature and sanitation issues, incomplete PBJ staffing data submission, and lapses in infection control during wound care and laundry cleanliness.
Deficiencies (12)
F 0565: The facility failed to act on Food Committee concerns as resident requests were not documented or addressed in food service.
F 0584: The facility failed to maintain residents' rooms and furnishings in a clean, safe, homelike, and sanitary manner with multiple maintenance issues observed across units.
F 0609: The facility failed to timely report allegations of resident-to-resident mistreatment to Adult Protective Services as required.
F 0644: The facility failed to refer Resident #98 for a PASRR Level II evaluation after a new psychiatric diagnosis was identified.
F 0677: The facility failed to provide timely incontinent care to a dependent resident, with care delayed approximately 4 hours beyond expected intervals.
F 0692: The facility failed to systematically assess and document daily fluid intake for residents on fluid restrictions, risking dehydration.
F 0757: The facility failed to follow physician orders for medication administration including failure to take blood pressure before Atenolol and incorrect Vitamin D3 dosing.
F 0761: The facility failed to date multi-dose medication vials upon opening and failed to discard expired medications timely.
F 0804: The facility failed to ensure food was palatable, attractive, and served at safe temperatures; meatloaf and cheesecake temperatures were below palatable standards.
F 0812: The facility failed to ensure food items were properly dated, stored, and served under sanitary conditions with multiple sanitation issues in kitchen and storage areas.
F 0851: The facility failed to submit Payroll Based Journal (PBJ) staffing data for the third quarter of 2023 as required by CMS.
F 0880: The facility failed to maintain proper infection control during wound care for a resident on Enhanced Barrier Precautions and failed to maintain a clean laundry environment.
Report Facts
Missed blood pressure readings: 340
Fluid restriction: 1200
Medication doses administered twice monthly: 2
Medication doses held: 4
Temperature of meatloaf: 120.4
Temperature of cheesecake: 77.7
Open multi-dose vial date exceeded: 66
Open multi-dose vial date exceeded: 7
Laundry cleaning schedule: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #6 | Licensed Practical Nurse | Failed to wear gown during wound care for Resident #77 on Enhanced Barrier Precautions |
| LPN #4 | Licensed Practical Nurse | Failed to take blood pressure before administering Atenolol to Resident #25 |
| LPN #10 | Licensed Practical Nurse | Administered Procrit despite hemoglobin above threshold for Resident #107 |
| APRN #1 | Advanced Practice Registered Nurse | Wrote incorrect Vitamin D3 order resulting in twice monthly dosing for Resident #107 |
| NA #5 | Nursing Assistant | Reported resident-to-resident mistreatment between Residents #80 and #140 |
| Director of Nursing Services | DNS | Failed to notify Adult Protective Services of resident-to-resident mistreatment |
| Dietary Manager | Failed to respond to Food Committee concerns and identified food temperature issues | |
| Regional Environmental Services Manager | Observed unclean laundry room conditions | |
| Environmental Services Director | Observed unclean laundry room conditions and open window in dryer room |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jul 25, 2024
Visit Reason
The inspection was conducted to investigate allegations of resident-to-resident mistreatment and failure to report suspected abuse, neglect, or theft to proper authorities, as well as to assess care related to incontinence for a dependent resident.
Complaint Details
The investigation was triggered by complaints of resident-to-resident mistreatment involving physical altercations and inappropriate touching. The facility did not notify Adult Protective Services for these incidents and failed to report some allegations to the state survey agency. The complaint was substantiated with findings of failure to report and inadequate response.
Findings
The facility failed to timely report allegations of resident-to-resident mistreatment to Adult Protective Services and the state survey agency. Multiple incidents involving physical altercations and inappropriate touching among residents with cognitive impairments were documented. Additionally, the facility failed to provide timely incontinent care to a dependent resident, with observations showing delays beyond the expected care intervals.
Deficiencies (2)
F 0609: The facility failed to timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Multiple resident-to-resident altercations were not reported to Adult Protective Services as required.
F 0677: The facility failed to provide timely incontinent care to a dependent resident, with care observed approximately 4 hours after the previous care instead of every 2 hours as planned.
Report Facts
Reportable Event dates: 4
Observation duration: 159
Incontinent care interval: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Reported allegation of mistreatment between Resident #80 and Resident #140 and participated in investigation. |
| LPN #3 | Licensed Practical Nurse | Provided information about incontinent care schedules and observations for Resident #103. |
| NA #2 | Nursing Assistant | Responsible for providing incontinent care to Resident #103 and admitted last care was 4 hours prior to observation. |
| Director of Nursing Services | Director of Nursing Services | Interviewed regarding failure to notify Adult Protective Services and state agency about resident-to-resident altercations and mistreatment. |
| Administrator | Facility Administrator | Interviewed about failure to report allegations of mistreatment to the State Agency. |
| RN #3 | Clinical Regional Director | Interviewed about failure to notify the state agency of mistreatment allegations. |
Inspection Report
Complaint Investigation
Census: 163
Capacity: 175
Deficiencies: 0
Date: Feb 20, 2024
Visit Reason
The inspection visit was conducted as a complaint investigation identified by complaint number #37377.
Complaint Details
Complaint investigation #37377 was conducted and found no violations; the complaint was not substantiated.
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.
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
Date: Jan 25, 2024
Visit Reason
The inspection visit was conducted as a complaint investigation related to Complaint Investigation #37061.
Complaint Details
Complaint Investigation #37061 was the basis for the visit. Violations were not identified at the time of this inspection.
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
| 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
Routine
Deficiencies: 2
Date: Mar 30, 2023
Visit Reason
The inspection was conducted to review compliance with care planning and clinical management for residents, including neglect concerns and dialysis care.
Findings
The facility failed to develop and implement a comprehensive care plan addressing a resident's refusal of care and failed to ensure medication review and dialysis communication documentation for a resident receiving dialysis.
Deficiencies (2)
F 0656: The facility failed to develop and implement a comprehensive care plan to address Resident #1's refusal of care, including refusals to turn and reposition, despite documented refusals and need for assistance every two hours.
F 0698: The facility failed to ensure medication prescribed prior to hospital transfer was reviewed upon readmission for Resident #4 and failed to maintain a dialysis communication documentation log.
Report Facts
Residents affected: 3
Frequency of refusal: 2
Dialysis frequency: 3
Potassium level: 6.4
Medication dosage: 8.4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Corporate RN | Identified lack of care plan addressing refusals for Resident #1 |
| RN #2 | Registered Nurse | Interviewed regarding medication review and readmission for Resident #4 |
| APRN #1 | Advanced Practice Registered Nurse | Verified and ordered medications for Resident #4 upon readmission |
| NA #1 | Nursing Assistant | Reported Resident #1's refusals of turning and repositioning |
| Rehabilitation Director | Interviewed about Resident #1's refusal of care and mobility | |
| MDS Coordinator | Responsible for reviewing and updating Resident #1's care plan | |
| Assistant Director of Nurses | ADNS | Interviewed about care plan documentation for Resident #1 |
Inspection Report
Complaint Investigation
Census: 162
Capacity: 175
Deficiencies: 0
Date: Dec 27, 2022
Visit Reason
The inspection visit was conducted as a complaint investigation related to Complaint Investigation # CT 00033230.
Complaint Details
Complaint Investigation # CT 00033230 was reviewed and no violations were substantiated.
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/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
Date: 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
Date: 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
Date: 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
Routine
Deficiencies: 10
Date: Apr 8, 2022
Visit Reason
Routine state inspection survey conducted 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 promote resident self-determination, improper management of resident personal funds, maintenance and cleanliness issues, failure to protect residents from abuse, inaccurate resident assessments, failure to revise care plans timely, improper disposal of sharps, inadequate personal hygiene care for dependent residents, and untimely physician order signatures. Infection control practices were also deficient, including improper lancet disposal and incomplete employee COVID-19 surveillance.
Deficiencies (10)
F 0561: The facility failed to assist Resident #82 with pursuing interests and choices, including getting out of bed and attending social activities despite having a specialized recliner available but improperly stored.
F 0568: The facility failed to provide timely quarterly financial statements to Resident #17 and other residents regarding their personal funds in the Resident Trust Account.
F 0584: The facility failed to maintain rooms and bathrooms in good repair, including rust, damage to walls and floors, leaking sinks, and fungal growth on faucets, and failed to clean malodorous stains promptly.
F 0600: The facility failed to protect Resident #7 from being slapped by Resident #55 during a resident-to-resident altercation.
F 0641: The facility failed to ensure accurate coding of residents' cognitive and mood status on Minimum Data Set (MDS) assessments, including inappropriate use of no information codes (dashes) and failure to complete assessments timely.
F 0657: The facility failed to review and revise the care plan for Resident #59 to reflect discontinuation of Hospice services and failed to have a system to invite residents and families to care plan meetings.
F 0658: The facility failed to properly dispose of a lancet after blood glucose testing by discarding it in the trash instead of a sharps container.
F 0677: The facility failed to provide adequate personal hygiene care, including fingernail trimming and shaving, for dependent residents #29, #70, #83, and #101 despite care plans indicating need for assistance.
F 0711: The facility failed to ensure physician orders for Resident #76 were signed and dated timely, with multiple months of orders unsigned.
F 0880: The facility failed to maintain an employee COVID-19 positive line list with required details such as symptom onset, resolution, and return to work dates.
Report Facts
Date of survey completion: Apr 8, 2022
Physician order signature dates: Dec 22, 2021
COVID-19 positive staff tracking period: 50
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NA #3 | Nursing Assistant | Witnessed resident-to-resident altercation involving Resident #7 and Resident #55 |
| NA #2 | Nursing Assistant | Witnessed resident-to-resident altercation involving Resident #7 and Resident #55 |
| LPN #1 | Licensed Practical Nurse | Observed improper disposal of lancet and failure to perform hand hygiene |
| Administrator | Interviewed regarding multiple deficiencies including resident care plan invitations and physician order signatures | |
| Director of Nursing Services (DNS) | Interviewed regarding physician order signatures and infection control practices | |
| Infection Preventionist | Interviewed regarding lancet disposal and hand hygiene | |
| Regional MDS Coordinator/RN #3 | Registered Nurse | Interviewed regarding MDS assessment inaccuracies and care plan revisions |
| Social Worker #1 | Social Worker | Interviewed regarding MDS completion and care plan meeting invitations |
| MD #1 | Physician | Interviewed regarding physician order signatures for Resident #76 |
Inspection Report
Plan of Correction
Census: 109
Capacity: 175
Deficiencies: 7
Date: 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.
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.
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.
Deficiencies (7)
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
Date: 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.
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.
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.
Deficiencies (6)
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
Date: 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.
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.
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.
Deficiencies (2)
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.
Failure to maintain proper infection prevention and control practices by not wearing a surgical mask at all times while providing care to Resident #2.
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
Date: 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
Date: 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.
Complaint Details
The visit was complaint-related and included a COVID-19 focused survey; no deficiencies were found.
Findings
No deficiencies were cited as a result of this survey.
Inspection Report
Monitoring
Deficiencies: 6
Date: 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)
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
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
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.
Deficiencies (5)
Acting Director of Nurses donned an N95 mask on top of a surgical mask, contrary to CDC guidance.
Residents on contact precautions were not properly masked or isolated; curtains were not fully drawn and residents ambulated without masks.
Staff wore surgical masks under N95 masks, and signage posted did not comply with infection control standards.
Residents on the secured dementia unit were not offered masks and did not maintain social distancing.
Gowns and face shields on the COVID unit were improperly stored, causing contamination and cross contamination risks.
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
Date: 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
Date: 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.
Complaint Details
Complaint Investigation #25285 was substantiated with violations identified related to resident transfer communication and care deficiencies.
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.
Deficiencies (7)
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
Date: 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.
Complaint Details
Complaint #25785 triggered the investigation.
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.
Deficiencies (1)
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
Date: 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.
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.
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.
Deficiencies (1)
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.
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
Date: 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.
Deficiencies (4)
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.
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.
Facility failed to properly dispose of garbage and refuse, with garbage debris and used gloves found around the exterior dumpster area.
Facility failed to establish and maintain an infection prevention and control program including lack of a comprehensive water management plan to reduce Legionella risk.
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
Date: 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.
Complaint Details
Complaint #23754 triggered the investigation and 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.
Deficiencies (8)
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
Routine
Deficiencies: 4
Date: Jan 15, 2019
Visit Reason
The inspection was conducted to assess compliance with health and safety regulations, including environmental conditions, food safety, infection control, and waste disposal at Autumn Lake Healthcare at Cromwell.
Findings
The facility was found to have multiple deficiencies including poor maintenance of resident areas with water stains and damaged fixtures, unsanitary kitchen conditions with rodent droppings and food contamination risks, improper garbage disposal around the dumpster area, and lack of a comprehensive water management plan to prevent Legionella risk.
Deficiencies (4)
F 0584: The facility failed to maintain a clean, well-maintained, and homelike environment with water stains, damaged bathroom fixtures, exposed wiring, and unsafe floor conditions in multiple resident rooms on the 2nd floor Maple unit.
F 0812: The dietary/kitchen area was unsanitary with uncovered food bins containing debris, rodent droppings on the floor, open garbage cans, undated open food containers, soiled equipment, and presence of rodents observed during the tray line service.
F 0814: The exterior dumpster area was not maintained in a clean and sanitary manner, with garbage debris and 13 pairs of used exam gloves found scattered around the area.
F 0880: The facility failed to provide and implement a water management plan to reduce Legionella risk, lacking documentation of process flow diagrams, control measures, and training for the Water Management Committee.
Report Facts
Weight of sugar bin: 40
Weight of flour bin: 25
Number of resident serving trays damaged: 100
Number of mouse traps: 6
Weight of thawing chicken: 20
Number of pairs of used exam gloves: 13
Chemical concentration in sanitizer bucket: 0
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Food Service Director (FSD) #1 | Interviewed regarding kitchen sanitation and food safety issues | |
| Corporate Manager #1 | Present during kitchen tour identifying sanitation deficiencies | |
| Maintenance Director | Interviewed about facility maintenance issues and bathtub water turned off | |
| Administrator | Interviewed about remodeling plans and water management plan absence | |
| Registered Nurse #1 | Infection Control Nurse (ICN) | Interviewed about use of resident nourishment room as staff break room and infection control concerns |
Inspection Report
Renewal
Census: 117
Capacity: 170
Deficiencies: 0
Date: 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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