Deficiencies (last 5 years)
Deficiencies (over 5 years)
15 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
168% worse than Connecticut average
Connecticut average: 5.6 deficiencies/yearDeficiencies per year
36
27
18
9
0
Occupancy
Latest occupancy rate
90% occupied
Based on a September 2024 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Plan of Correction
Census: 255
Capacity: 282
Deficiencies: 0
Date: 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
Complaint Investigation
Deficiencies: 2
Date: Jul 18, 2024
Visit Reason
The inspection was conducted to investigate complaints related to discharge planning and medication administration for Resident #1 at Autumn Lake Healthcare at New Britain.
Complaint Details
The complaint investigation focused on discharge planning and medication administration for Resident #1. The complaint was substantiated with findings of delayed homecare notification and failure to administer prescribed medication as ordered.
Findings
The facility failed to notify the homecare agency timely of a resident's discharge, delaying the start of care. Additionally, the facility failed to follow physician's orders regarding administration of a glaucoma medication, resulting in missed doses.
Deficiencies (2)
F 0622: The facility failed to notify the homecare agency timely of Resident #1's discharge, delaying the start of physical therapy, occupational therapy, and skilled nursing services by three days.
F 0684: The facility failed to follow physician's orders for administering Latanoprost ophthalmic solution to Resident #1, resulting in missed doses due to medication availability and documentation gaps.
Report Facts
Residents reviewed: 3
Residents affected: 1
Days delay: 3
Medication administration notes: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Home Health Intake Nurse | Interviewed regarding delayed notification to homecare agency |
| Social Worker #1 | Interviewed regarding discharge planning documentation | |
| DNS | Director of Nursing Services | Interviewed regarding medication delivery and administration policies |
| Pharmacist | Interviewed regarding medication delivery and impact of missed doses |
Inspection Report
Monitoring
Census: 247
Capacity: 282
Deficiencies: 0
Date: 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
Deficiencies: 1
Date: Jun 11, 2024
Visit Reason
The inspection was conducted to assess compliance with care planning requirements, specifically regarding the development and implementation of a comprehensive care plan for residents.
Findings
The facility failed to develop a comprehensive care plan addressing refusals of tracheal humidification for Resident #2, despite documented refusals and education provided. The care plan did not include interventions for the resident's refusal to use humidification as prescribed.
Deficiencies (1)
F 0656: The facility failed to develop and implement a complete care plan that meets all the resident's needs, including refusals of tracheal humidification for Resident #2. The care plan did not address the resident's frequent refusal of humidification despite education and physician orders.
Inspection Report
Routine
Deficiencies: 7
Date: May 10, 2024
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to medication administration, resident rights, assessments, care planning, staff performance, medication storage, and infection control at Autumn Lake Healthcare at New Britain.
Findings
The facility was found deficient in multiple areas including failure to assess a resident for medication self-administration, discrepancies between physician orders and advance directives, late completion of quarterly MDS assessments, incomplete care plans for residents on anticoagulants, lack of annual performance evaluations for nurse aides, improper storage of expired medications, and inadequate infection prevention practices related to MDRO cohorting.
Deficiencies (7)
F 0554: The facility failed to ensure Resident #166 was assessed for self-administration of medications and left medications at bedside without nurse supervision.
F 0578: The facility failed to ensure physician's orders and Resident #126's signed Advance Directives were congruent regarding code status.
F 0638: The facility failed to complete and submit quarterly MDS assessments for Residents #25, #104, and #170 within prescribed timing parameters.
F 0656: The facility failed to develop care plans addressing side effects and monitoring for anticoagulant therapy for Residents #81 and #160.
F 0730: The facility failed to complete annual performance evaluations for nurse aides NA #1 and NA #3.
F 0761: The facility failed to store medications properly, including expired medications in the medication room and refrigerator.
F 0880: The facility failed to identify and maintain records of residents with known MDRO colonization and failed to appropriately cohort residents with MDROs.
Report Facts
Days late for MDS completion: 40
Days late for MDS completion: 11
Days late for MDS completion: 58
Days late for MDS completion: 51
Medication doses administered after expiration: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #2 | Licensed Practical Nurse | Named in medication self-administration observation and interview regarding Resident #166 |
| LPN #1 | MDS Coordinator | Named in interviews regarding late MDS assessments and care plan deficiencies |
| RN #3 | Registered Nurse | Named in interview regarding care plan deficiencies for anticoagulant therapy |
| DNS | Director of Nursing Services | Named in multiple interviews regarding medication administration, care plans, and infection control |
| HR #1 | Human Resources | Named in interview regarding nurse aide performance evaluations |
| LPN #4 | Licensed Practical Nurse | Named in observation and interview regarding expired medications in medication room |
| Pharmacist #1 | Pharmacist | Named in interview regarding medication expiration and storage |
| LPN #8 | Infection Preventionist Nurse | Named in interview regarding MDRO log and infection control practices |
| RN #2 | Unit Manager/Supervisor | Named in interview regarding care plan development for anticoagulant therapy |
Inspection Report
Routine
Deficiencies: 11
Date: May 10, 2024
Visit Reason
Routine inspection of Autumn Lake Healthcare at New Britain to assess compliance with healthcare regulations including medication administration, resident care, infection control, and documentation.
Findings
The facility had multiple deficiencies including failure to assess a resident for medication self-administration, discrepancies in advance directives and physician orders, failure to notify physician and family of significant weight loss, late completion of resident assessments, incomplete care plans for anticoagulant therapy, lack of physician orders for splint use, administration of expired medication, failure to maintain infection control cohorting, and incomplete nurse aide performance evaluations.
Deficiencies (11)
F 0554: Facility failed to ensure Resident #166 was assessed for self-administration of medications and nurses left medications at bedside without proper supervision.
F 0578: Facility failed to ensure physician's order and Resident #126's signed Advance Directives were congruent regarding code status.
F 0580: Facility failed to notify physician and resident representative of significant weight loss for Resident #87 and failed to document monthly weights from August to December 2023.
F 0638: Facility failed to complete quarterly MDS assessments timely for Residents #25, #104, and #170, with delays ranging from 11 to 58 days.
F 0656: Facility failed to develop and implement care plans addressing side effects and monitoring for anticoagulant therapy for Residents #81 and #160.
F 0658: Facility failed to ensure physician's order was in place for use of splints for Resident #42 and failed to ensure expired Lansoprazole medication was not administered to Resident #213.
F 0684: Facility failed to ensure Lansoprazole oral suspension was administered as ordered to Resident #213; medication was expired and administration was inaccurately documented.
F 0692: Facility failed to ensure dietician assessed Resident #87 timely for weight loss and failed to obtain monthly weights as ordered from August to December 2023.
F 0730: Facility failed to complete annual performance evaluations for nurse aides NA #1 and NA #3; only annual competencies were completed.
F 0761: Facility failed to store medications appropriately; multiple expired medications including Lansoprazole suspension were found and administered to Resident #213.
F 0880: Facility failed to identify and maintain records of residents with known MDRO colonization and failed to appropriately cohort residents with MDROs, placing Residents #42 and #230 with different MDRO histories in the same room.
Report Facts
Days late for MDS completion: 40
Days late for MDS completion: 11
Days late for MDS completion: 58
Days late for MDS completion: 51
Weight loss percentage: 13
Weight loss percentage: 10.1
Medication administration days post expiration: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #2 | Licensed Practical Nurse | Named in medication self-administration observation and interview regarding Resident #166 |
| LPN #1 | MDS Coordinator | Acknowledged late MDS assessments and care plan deficiencies |
| RN #3 | Registered Nurse | Identified care plan deficiencies for anticoagulant therapy |
| DNS | Director of Nursing Services | Provided multiple interviews regarding deficiencies and facility policies |
| Dietician #2 | Dietician | Conducted nutritional evaluation and identified weight loss issues for Resident #87 |
| RN #1 | Wound Nurse/Unit Manager | Interviewed regarding weight monitoring and notification responsibilities |
| LPN #4 | Licensed Practical Nurse | Identified expired medication and interviewed about medication administration |
| LPN #3 | Licensed Practical Nurse | Admitted medication administration error for Resident #213 |
| OT #1 | Assistant Director of Rehab/Occupational Therapist | Interviewed regarding splint usage and physician orders |
| LPN #8 | Infection Preventionist Nurse | Interviewed regarding MDRO log and infection control practices |
| HR #1 | Human Resources | Interviewed regarding nurse aide performance evaluations |
Inspection Report
Plan of Correction
Census: 244
Capacity: 282
Deficiencies: 2
Date: 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)
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
Date: 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
Complaint Investigation
Deficiencies: 2
Date: Sep 27, 2023
Visit Reason
The inspection was conducted following a complaint regarding medication errors and failure to obtain ordered laboratory tests for a newly admitted resident.
Complaint Details
The investigation was triggered by a complaint from Resident #1's spouse regarding the omission of thyroid medication during the resident's stay. The complaint was substantiated by clinical record reviews and interviews.
Findings
The facility failed to transcribe and administer a prescribed thyroid medication (Levothyroxine) for 27 days to Resident #1, resulting in a significant medication error. Additionally, the facility did not obtain ordered laboratory blood work (CBC and CMP) for the resident as directed by the physician.
Deficiencies (2)
F 0760: The facility failed to transcribe and administer Levothyroxine upon admission, resulting in Resident #1 missing 27 doses over 28 days. Distractions during transcription and missed checks contributed to the omission.
F 0773: The facility failed to obtain ordered laboratory blood work (CBC and CMP) on 7/27/23 for Resident #1, with no documentation or results found. The reason for the omission was unknown.
Report Facts
Days medication omitted: 28
Doses missed: 27
TSH level: 6.1
Date of physician order for labs: Jul 25, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | 7AM-3PM Unit Manager, Registered Nurse | Named in medication transcription error due to distraction. |
| RN #2 | 11PM-7AM Nursing Supervisor, Registered Nurse | Responsible for second reconciliation of admission orders; could not recall missing Synthroid order. |
| Director of Nurses | Director of Nurses (DON) | Described transcription and order review process; noted failures in checks for omitted medication and missing lab results. |
| APRN #1 | Advanced Practice Registered Nurse | Expected CBC and CMP labs to be drawn per physician order. |
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Nov 24, 2021
Visit Reason
The inspection was conducted as a standard annual survey to assess compliance with regulatory requirements and quality of care at Autumn Lake Healthcare at New Britain.
Findings
The facility was found deficient in accurately transcribing and updating advance directives, properly documenting medication orders and administration, and ensuring appropriate respiratory care equipment handling. Deficiencies involved minimal harm or potential for actual harm affecting a few residents.
Deficiencies (3)
F 0578: The facility failed to ensure the physician's orders reflected the resident's updated advance directive, resulting in conflicting code status documentation for Resident #538.
F 0658: The facility failed to transcribe a physician's order correctly regarding the indication for use of an as needed medication for Resident #539, leading to incomplete documentation and inconsistent medication administration.
F 0695: The facility failed to provide necessary respiratory care consistent with professional practice by not properly storing nebulizer masks between uses for Resident #77.
Report Facts
Medication duration: 14
Medication duration: 3
Observation dates: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Advanced Practice Registered Nurse #1 | APRN | Interviewed regarding medication order changes for Resident #539 |
| Registered Nurse #3 | Nursing Supervisor | Interviewed about Resident #539's behavior and medication administration |
| Registered Nurse #2 | RN | Admitted Resident #539 and discussed medication order changes |
| Advanced Practice Registered Nurse #2 | APRN | Interviewed about medication order changes for Resident #539 |
| Registered Nurse #1 | RN | Interviewed about nebulizer mask storage for Resident #77 |
| Assistant Director of Nursing | ADON | Interviewed about advance directive transcription for Resident #538 |
| Assistant Director of Nursing Services | ADNS | Interviewed about nebulizer mask storage policy |
Inspection Report
Plan of Correction
Deficiencies: 3
Date: 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)
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
Date: Nov 17, 2021
Visit Reason
The inspection was conducted as a renewal licensing inspection with review of complaint investigations.
Complaint Details
Complaint investigations #25720, #28929, #30103, #31144, #29891, #24629, #28157, #27004, #29006 were reviewed during the inspection.
Findings
The inspection included review of complaint investigations and verification of compliance with licensing requirements. No violations were explicitly noted on this form.
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
Date: 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.
Complaint Details
Complaint #29711 was the basis for the 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.
Deficiencies (2)
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
Date: 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)
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
Date: 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.
Deficiencies (4)
Failure to secure hazardous chemicals on unattended housekeeping carts, posing accident hazards.
Failure to adequately store resident facemasks, risking potential spread of infection.
Failure to ensure residents were cohorted on the appropriate cohort after completing COVID-19 observation status.
Failure of housekeeping and nursing staff to don required PPE, including eye protection, when caring for residents on COVID-19 positive and observation units.
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
Date: 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
Date: 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
Date: 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
Date: 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
Date: 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
Date: 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
Date: 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
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
Plan of Correction
Deficiencies: 8
Date: 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)
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
Date: 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)
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
Date: 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.
Deficiencies (7)
Failure to ensure Resident #35's financial representative received quarterly statements.
Failure to maintain a homelike environment including torn carpeting and ceiling stains in resident rooms.
Failure to notify the State Agency timely about a resident alleging physical mistreatment.
Failure to develop and implement a comprehensive care plan including specific Multi Drug Resistant Organism (MDRO) for Resident #7.
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.
Failure to apply physician-directed interventions for pressure ulcers including offloading boots for Resident #211.
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.
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
Routine
Deficiencies: 7
Date: Jun 11, 2019
Visit Reason
Routine state inspection survey conducted to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in multiple areas including management of residents' personal funds, maintaining a safe and homelike environment, timely reporting of suspected abuse, comprehensive care planning for infections, medication administration, scheduling of specialty consultations, pressure ulcer care, and infection control practices.
Deficiencies (7)
F 0568: The facility failed to ensure Resident #35's financial representative received quarterly statements for personal funds management.
F 0584: The facility failed to maintain a safe, clean, and homelike environment, including torn and dirty carpeting and unaddressed ceiling and wall stains in resident rooms.
F 0609: The facility failed to timely report suspected abuse when Resident #179 alleged mistreatment, resulting in untimely submission of the report to the State Agency.
F 0656: The facility failed to develop and implement a comprehensive care plan for Resident #7 to include management of Multi Drug Resistant Organism (MDRO) ESBL infection.
F 0684: The facility failed to administer medications according to physician orders for Resident #31 and failed to ensure timely scheduling of a Rheumatology consultation for Resident #82.
F 0686: The facility failed to provide appropriate pressure ulcer care for Resident #211 by not applying physician-ordered offloading boots to bilateral heel wounds.
F 0880: The facility failed to implement infection prevention and control practices by not donning personal protective equipment for Resident #7 on contact isolation and improperly administering medications after they fell on the floor for Resident #64.
Report Facts
Medication units: 3
Pressure ulcer size left heel: 4.5
Pressure ulcer size right heel: 3
Inspection Report
Deficiencies: 2
Date: 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)
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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