Inspection Report Summary
The most recent inspection on September 27, 2024, found that previously cited violations had been corrected. Earlier inspections showed a pattern of deficiencies related primarily to resident care documentation, medication management, and infection control practices. Complaint investigations reviewed were mostly unsubstantiated, and no fines, immediate jeopardy findings, or license actions were listed in the available reports. Prior reports noted issues with transcription of physician orders, medication scheduling, respiratory care, and PPE use, but these were addressed through plans of correction. The facility’s record indicates improvement over time, with recent audits confirming correction of earlier deficiencies.
Deficiencies (last 5 years)
Deficiencies (over 5 years)
8.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
50% worse than Connecticut average
Connecticut average: 5.6 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
90% occupied
Based on a September 2024 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Plan of Correction
Census: 255
Capacity: 282
Deficiencies: 0
Sep 27, 2024
Visit Reason
A desk audit was completed on 9/27/2024 for the purpose of reviewing the implementation of the Plan of Correction for the Violation letter dated 7/30/2024.
Findings
Violations #1 and #2 were identified as corrected as of 8/28/2024. The Director of Nurses, Alexandra Chin, was notified via telephone that all violations were corrected.
Report Facts
Licensed Bed Capacity: 282
Census: 255
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alexandra Chin | Director of Nurses | Named in notification of correction of violations |
Inspection Report
Monitoring
Census: 247
Capacity: 282
Deficiencies: 0
Jul 17, 2024
Visit Reason
A desk audit was conducted to review the implementation of the Plan of Correction for a Violation Letter dated 5/10/24.
Findings
Violations #1, #3, #4, #5, #6, #7, #8, #9, and #10 were identified as corrected as of 6/18/24, and violation #2 was identified and corrected as of 6/20/24. The administrator was notified via telephone that all violations were corrected.
Report Facts
Violation numbers corrected: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Josh Schechter | Administrator | Notified via telephone that all violations were corrected. |
| Reba Stoddard | RN NC | Report submitted by. |
Inspection Report
Plan of Correction
Census: 244
Capacity: 282
Deficiencies: 2
Nov 22, 2023
Visit Reason
A desk audit was conducted on 11/22/23 to review the implementation of the plan of correction for violations cited in a letter dated 10/5/23.
Findings
Violations 1a and 2a were corrected as of 11/6/23. The administrator and Department of Social Services were notified via telephone on 11/22/23 at 10:21 am that all violations were corrected.
Deficiencies (2)
| Description |
|---|
| Violation 1a |
| Violation 2a |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Joshua Schechter | Administrator | Named in notification of correction of violations |
| Alexandra Chin | DHS | Named in notification of correction of violations |
Inspection Report
Follow-Up
Census: 244
Capacity: 282
Deficiencies: 0
Nov 22, 2023
Visit Reason
A desk audit was conducted on 11/22/23 to review the implementation of the plan of correction for violations identified in a prior letter dated 10/05/23.
Findings
Violations #1a and 2a were corrected as of 11/06/23. On 11/22/23 at 10:21 am, the administrator and DNS were notified via telephone that all violations were corrected.
Report Facts
Licensed Bed/Bassinet Capacity: 282
Census: 244
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Joshua Schechter | Administrator | Personnel contacted during inspection and notified of correction status |
| Alexandra Chin | DNS | Personnel contacted during inspection and notified of correction status |
Inspection Report
Plan of Correction
Deficiencies: 3
Nov 24, 2021
Visit Reason
Unannounced visits were made to Autumn Lake Healthcare At New Britain which concluded on November 24, 2021, by representatives of the Facility Licensing and Investigations Section of the Department of Public Health for the purpose of conducting multiple investigations and a recertification survey.
Findings
The report details violations of Connecticut State Agencies regulations identified during the visits, including failures in transcription of physician orders, medication administration documentation, respiratory care, and notification of condition changes. The facility submitted a plan of correction addressing these issues.
Deficiencies (3)
| Description |
|---|
| Failure to transcribe a physician's order from the discharging facility to include the indication of use directive for an as needed medication for Resident #539. |
| Failure to provide necessary respiratory care consistent with professional practice for Resident #77, including improper storage of nebulizer masks. |
| Failure to ensure documentation of physician or nurses notes related to the ordering and use of cough medication for Resident #638. |
Report Facts
Date of inspection visit: Nov 24, 2021
Plan of correction submission deadline: Dec 30, 2021
Plan of correction dispute deadline: Dec 26, 2021
Plan of correction monitoring period: 90
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Norma Schuberth | Supervising Nurse Consultant | Signed letter regarding plan of correction instructions |
| Joshua Schechter | Administrator | Facility administrator addressed in the letter |
Inspection Report
Renewal
Census: 245
Capacity: 282
Deficiencies: 0
Nov 17, 2021
Visit Reason
The inspection was conducted as a renewal licensing inspection with review of complaint investigations.
Findings
The inspection included review of complaint investigations and verification of compliance with licensing requirements. No violations were explicitly noted on this form.
Complaint Details
Complaint investigations #25720, #28929, #30103, #31144, #29891, #24629, #28157, #27004, #29006 were reviewed during the inspection.
Report Facts
Census: 245
Total Capacity: 282
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Joshua Schechter | Administrator | Personnel contacted during inspection |
Inspection Report
Plan of Correction
Deficiencies: 2
Mar 22, 2021
Visit Reason
An unannounced visit was made to Autumn Lake Healthcare at New Britain on March 22, 2021, by a representative of the Facility Licensing and Investigations Section of the Department of Public Health for the purpose of conducting an investigation.
Findings
Violations of Connecticut State Agencies regulations were noted during the visit, including failures to ensure medications were scheduled to accommodate residents' dialysis schedules and failures to document blood sugar tests and results for a resident receiving insulin.
Complaint Details
Complaint #29711 was the basis for the investigation.
Deficiencies (2)
| Description |
|---|
| Failure to ensure medications were scheduled to accommodate Resident #1's dialysis schedule, resulting in omission of medications on dialysis days. |
| Failure to document blood sugar tests and results in the clinical record for Resident #1 who received insulin. |
Report Facts
Dialysis days with missed 1:00 PM medication doses: 4
Blood sugar tests required per day: 4
Blood sugar test results documented: 5
Sampled residents: 3
Plan of correction reporting period: 90
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Karen Gworek | Supervising Nurse Consultant | Author of the notice letter regarding the plan of correction. |
| Joshua Schechter | Administrator | Recipient of the notice letter. |
| Advanced Practice Registered Nurse (APRN) #1 | Interviewed regarding medication administration and scheduling. | |
| Director of Nursing (DON) | Interviewed regarding medication scheduling and documentation expectations. | |
| Registered Nurse (RN) #1 | Interviewed regarding medication administration on dialysis days. |
Inspection Report
Abbreviated Survey
Deficiencies: 3
Jan 28, 2021
Visit Reason
An unannounced visit was conducted at Autumn Lake Healthcare At New Britain on January 28, 2021, by the Department of Public Health for the purpose of conducting a Covid-19 focused infection control survey.
Findings
The facility was found noncompliant with regulations related to infection control, including failure to secure hazardous chemicals on housekeeping carts, improper storage of residents' facemasks, failure to cohort residents appropriately, and failure of staff to use required personal protective equipment (PPE) properly.
Deficiencies (3)
| Description |
|---|
| Failure to secure hazardous chemicals on unattended housekeeping carts. |
| Failure to adequately store residents' facemasks, ensure proper cohorting, and ensure housekeeping staff donned required PPE. |
| Failure of staff to utilize appropriate PPE when caring for residents on observation and COVID-19 positive units. |
Report Facts
Date of inspection: Jan 28, 2021
Plan of correction submission deadline: Feb 19, 2021
Number of spray bottles on housekeeping carts: 4
Number of wheelchairs observed: 6
Number of residents identified in cohorting failure: 4
Number of days for observation status: 14
Number of days for plan of correction oversight: 90
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Judith Birtwistle | Supervising Nurse Consultant | Author of the amended notice letter |
| Joshua Schechter | Administrator | Facility administrator addressed in the letter and responsible for oversight of plan of correction |
| Housekeeper #1 | Observed with unlocked housekeeping cart and interviewed about chemical storage | |
| Housekeeper #2 | Interviewed about locking housekeeping cart after surveyor inquiry | |
| Housekeeper #3 | Observed entering hallway and directed to lock housekeeping cart; later directed to don eye protection | |
| Director of Nurses (DNS) | Interviewed regarding wheelchair placement, mask usage, and PPE policies | |
| Nurse Manager (RN #1) | Dementia Unit Nurse Manager | Interviewed about Resident #5's ambulation and seating in hallway |
| Nurse Aide (NA #2) | Interviewed about surgical mask placement on residents | |
| Nursing Assistant (NA #1) | Observed exiting room without eye protection and directed to don face shield |
Inspection Report
Routine
Census: 229
Capacity: 282
Deficiencies: 4
Jan 28, 2021
Visit Reason
A COVID-19 Focused Infection Control 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 transmission of COVID-19.
Findings
The facility was found deficient in securing hazardous chemicals on housekeeping carts, proper storage of resident facemasks, appropriate cohorting of residents after COVID-19 observation periods, and ensuring staff donned required Personal Protective Equipment (PPE) when caring for residents on COVID-19 observation and positive units.
Severity Breakdown
SS=E: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to secure hazardous chemicals on unattended housekeeping carts, posing accident hazards. | SS=E |
| Failure to adequately store resident facemasks, risking potential spread of infection. | SS=E |
| Failure to ensure residents were cohorted on the appropriate cohort after completing COVID-19 observation status. | SS=E |
| Failure of housekeeping and nursing staff to don required PPE, including eye protection, when caring for residents on COVID-19 positive and observation units. | SS=E |
Report Facts
Census: 229
Total Capacity: 282
Housekeeping carts observed unsecured: 3
Residents on COVID-19 observation unit not cohorted properly: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Housekeeper #1 | Observed with unlocked housekeeping cart containing hazardous chemicals | |
| Housekeeper #2 | Observed with unlocked housekeeping cart containing hazardous chemicals | |
| Housekeeper #3 | Observed with unlocked housekeeping cart and not wearing required eye protection | |
| Director of Nursing (DNS) | Interviewed regarding cohorting and PPE compliance; directed staff to don PPE | |
| Nursing Assistant (NA) #1 | Observed exiting COVID-19 positive resident rooms without eye protection | |
| Nurse Manager (RN #1) | Interviewed regarding resident #5's ambulation and behavior | |
| Director of Housekeeping and Laundry | Interviewed regarding housekeeping cart security policy |
Inspection Report
Monitoring
Census: 202
Capacity: 282
Deficiencies: 0
Jun 24, 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 monitoring survey conducted at Autumn Lake Healthcare at New Britain.
Report Facts
Capacity: 282
Census: 202
Inspection Report
Monitoring
Census: 202
Capacity: 282
Deficiencies: 0
Jun 15, 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 the COVID-19 monitoring survey conducted on 6/15/20 at Autumn Lake Healthcare at New Britain.
Inspection Report
Abbreviated Survey
Census: 200
Capacity: 282
Deficiencies: 0
Jun 4, 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
Routine
Census: 195
Capacity: 282
Deficiencies: 0
May 27, 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: 282
Census: 195
Inspection Report
Abbreviated Survey
Census: 191
Capacity: 282
Deficiencies: 0
May 20, 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 the facility compliant with infection prevention and control practices related to COVID-19. No deficiencies were cited as a result of this survey.
Report Facts
Capacity: 282
Census: 191
Inspection Report
Abbreviated Survey
Deficiencies: 0
May 5, 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
Routine
Census: 192
Capacity: 282
Deficiencies: 0
May 5, 2020
Visit Reason
The visit was conducted for the purpose of an Infection Control (IC) survey.
Findings
The report does not provide detailed findings or deficiencies; it only indicates that the inspection was an IC survey with no violations or citations noted on the form.
Report Facts
Licensed Bed Capacity: 282
Census: 192
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alexandra Chin | Director of Nurses | Personnel contacted during the inspection |
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
Plan of Correction
Deficiencies: 8
Jun 17, 2019
Visit Reason
Unannounced visits were made to Autumn Lake Healthcare At New Britain on June 17, 18, 19 and 21, 2019 by representatives of the Facility Licensing and Investigations Section of the Department of Public Health for the purpose of conducting multiple investigations.
Findings
The report details multiple violations of Connecticut State Agencies regulations related to clinical record review, facility documentation, and interviews concerning resident care, including failure to notify physicians of weight changes, incomplete care plans, inadequate discharge planning, failure to prevent falls, and incomplete behavior monitoring. Plans of correction are included for each violation.
Deficiencies (8)
| Description |
|---|
| Failure to notify the physician when an increased weight was identified for Resident #9. |
| Failure to ensure the care plan was revised to include interventions to address behaviors to prevent injury for Resident #8. |
| Failure to ensure adequate evaluation for medical needs and proper medical equipment upon discharge for Resident #9. |
| Failure to ensure behaviors were addressed to prevent falls for Resident #8. |
| Failure to monitor respiratory status and obtain daily weights for Residents #2 and #9. |
| Failure to ensure medication prescribed by consulting physician was transcribed and ordered for Resident #3. |
| Failure to ensure proper documentation in transfer documents for Resident #1. |
| Failure to provide investigation regarding injury of unknown origin for Resident #10. |
Report Facts
Complaint numbers: 10
Dates of visits: 4
Weight gain: 8
Medication doses missed: 3
Urine specimen volume: 400
Blood pressure: 88
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Karen Gworek | Supervising Nurse Consultant | Signed letter on page 3 |
| Joshua Schechter | Administrator | Administrator of Autumn Lake Healthcare at New Britain mentioned throughout report |
| Director of Nursing | Interviewed and referenced multiple times in relation to findings and plans of correction | |
| Medical Doctor #1 | MD | Interviewed regarding weight gain notification and discharge planning |
| Registered Nurse #3 | RN | Wrote nurse's note regarding bruising on Resident #8 |
| Registered Nurse #2 | RN | Charge nurse at time of fall for Resident #8 |
| Licensed Practical Nurse #5 | LPN | Charge nurse at time of fall for Resident #8 |
| Advanced Practice Registered Nurse #2 | APRN | Reviewed and wrote orders related to Resident #8 and #9 |
| Respiratory Therapist | Interviewed regarding oxygen and nebulizer treatments for Resident #9 | |
| Assistant Director of Nursing | ADON | Interviewed regarding transfer documentation for Resident #1 |
Inspection Report
Renewal
Deficiencies: 11
Jun 11, 2019
Visit Reason
Unannounced visits were made to Autumn Lake Healthcare At New Britain on June 11, 2019, by representatives of the Department of Public Health for the purpose of conducting a licensure renewal inspection and a certification survey.
Findings
The report identifies multiple violations of Connecticut State General Statutes and Regulations, including deficiencies in resident care plans, facility environment, medication administration, infection control, and abuse prevention. The facility was found to have failed in ensuring proper documentation, timely interventions, and adequate staff education related to these areas.
Deficiencies (11)
| Description |
|---|
| Failure to ensure Resident #35's financial representative received quarterly statements and proper documentation of financial matters. |
| Facility failed to maintain a home-like environment in Room #212 with torn and frayed walls and ceiling stains. |
| Failure to ensure Resident #179 was free from abuse and timely reporting of alleged mistreatment. |
| Failure to ensure Resident #7's care plan included management of Multi Drug Resistant Organism (MDRO) and documentation of ESBL infection. |
| Failure to ensure Resident #31 received physician-directed medication administration and timely scheduling for diabetes management. |
| Failure to ensure Resident #82 received appropriate pain management, diagnostic testing, and rheumatology consultation. |
| Failure to ensure Resident #143 received physician-directed medication administration and monitoring for behavioral disturbances. |
| Failure to ensure Residents #7 and #64 were free from abuse and that staff were properly educated on personal protective equipment (PPE) use. |
| Failure to ensure Resident #211 received physician-directed interventions for pressure ulcers and proper documentation of wound care. |
| Failure to ensure Resident #230's discharge plan was complete and included interdisciplinary team involvement. |
| Failure to ensure Resident #230's care plan included re-evaluation and proper documentation of clinical records. |
Report Facts
Plan of Correction effective date: 2019
Resident sample size: 4
Dates of Minimum Data Set assessments: 2019
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Judith Birtwistle | Supervising Nurse Consultant | Signed letter regarding plan of correction and survey findings |
| Joshua Schechter | Administrator | Facility administrator named in relation to findings and plan of correction |
Inspection Report
Annual Inspection
Deficiencies: 7
Jun 11, 2019
Visit Reason
Unannounced visits were made to the facility on 6/4/19, 6/5/19, 6/6/19, 6/10/19 and 6/11/19 by representatives of the Facility Licensing & Investigations Section for the purpose of conducting a certification survey.
Findings
The facility was found deficient in multiple areas including failure to provide quarterly financial statements to a resident's financial representative, failure to maintain a homelike environment due to torn carpeting and ceiling stains, failure to timely report alleged physical mistreatment, incomplete care plans for residents with infections, medication administration errors, failure to timely schedule rheumatology consultation, failure to apply physician-directed pressure ulcer interventions, and failure to follow infection control protocols including PPE use and medication administration.
Severity Breakdown
SS=B: 1
SS=D: 6
Deficiencies (7)
| Description | Severity |
|---|---|
| Failure to ensure Resident #35's financial representative received quarterly statements. | SS=B |
| Failure to maintain a homelike environment including torn carpeting and ceiling stains in resident rooms. | SS=D |
| Failure to notify the State Agency timely about a resident alleging physical mistreatment. | SS=D |
| Failure to develop and implement a comprehensive care plan including specific Multi Drug Resistant Organism (MDRO) for Resident #7. | SS=D |
| Failure to administer medications in accordance with physician orders and failure to ensure timely scheduling for a Rheumatology consultation for Resident #31 and Resident #82 respectively. | SS=D |
| Failure to apply physician-directed interventions for pressure ulcers including offloading boots for Resident #211. | SS=D |
| Failure to don personal protective equipment (PPE) for a resident on transmission based precautions and failure to administer medication in accordance with infection control standards. | SS=D |
Report Facts
Deficiencies cited: 7
Resident #35 monthly funds after expenses: 16
Pressure ulcer measurements: 5
Pressure ulcer measurements: 4.5
Medication dosage: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN #2 | Licensed Practical Nurse | Named in medication administration error for Resident #31 and medication administration after medication spilled for Resident #64 |
| Person #3 | Financial Conservator | Named in failure to receive quarterly financial statements for Resident #35 |
| RN #1 | Registered Nurse | Responsible for setting up referrals and involved in Rheumatology referral delay for Resident #82 |
| Unit Secretary #1 | Responsible for arranging referrals and involved in Rheumatology referral delay for Resident #82 | |
| LPN #1 | Licensed Practical Nurse | Named in failure to don PPE for Resident #7 on transmission based precautions |
Inspection Report
Deficiencies: 2
Jun 11, 2019
Visit Reason
The inspection was conducted to review isolated deficiencies related to resident records and identifiable information, focusing on compliance with medical record maintenance and care plan documentation requirements.
Findings
The facility failed to ensure clinical records were complete for sampled residents, including missing timely Abnormal Involuntary Movement Scale (AIMs) evaluations and incomplete documentation of care plan meeting attendance.
Deficiencies (2)
| Description |
|---|
| Failure to maintain complete clinical records, including missing AIMs evaluations for Resident #143. |
| Failure to document care plan meeting attendance accurately for Resident #230. |
Report Facts
Number of sampled residents reviewed for unnecessary medication: 1
Number of sampled residents reviewed for care plan meeting attendance: 1
Date of last AIMs evaluation: Oct 25, 2018
Date of APRN progress note indicating AIMs evaluation: Apr 15, 2019
Date of Resident Care Plan update: Apr 18, 2019
Date of admission for Resident #143: Aug 8, 2018
Date of admission for Resident #230: May 3, 2019
Date of Minimum Data Set assessment for Resident #143: Apr 11, 2019
Date of Minimum Data Set assessment for Resident #230: May 10, 2019
Date of care plan meeting for Resident #230: May 17, 2019
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN #3 | Registered Nurse | Interviewed regarding AIMs evaluation and clinical record completeness for Resident #143 |
| RN #7 | Minimum Data Set Coordinator | Interviewed regarding care plan meeting attendance documentation for Resident #230 |
| Director of Social Services | Interviewed regarding care plan meeting for Resident #230 |
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