Deficiencies (last 7 years)
Deficiencies (over 7 years)
8.1 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
45% worse than Connecticut average
Connecticut average: 5.6 deficiencies/year
Deficiencies per year
28
21
14
7
0
Occupancy
Latest occupancy rate
97% occupied
Based on a June 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Census: 146
Capacity: 150
Deficiencies: 0
Date: Jun 3, 2025
Visit Reason
The inspection was a desk audit conducted on 6/3/25 to review compliance with the General Statutes of Connecticut and regulations of Connecticut State Agencies.
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 |
|---|---|---|
| Izabela Grabarz | Director of Nursing | Personnel contacted during the inspection and notified by telephone that all violations were corrected. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Mar 19, 2025
Visit Reason
The inspection was conducted following a complaint regarding the facility's failure to ensure accurate and consistent documentation of advance directives and code status for Resident #1, including failure to notify the responsible party of a change in condition and death.
Complaint Details
The complaint investigation focused on Resident #1's advance directives and quality of care. The complaint was substantiated with findings that the facility had conflicting code status documentation and failed to notify the court appointed Conservator of Person after the resident's death.
Findings
The facility failed to ensure the medical record included accurate advance directives and consistent code status documentation for Resident #1. The facility also failed to document notification of the responsible party after the resident's death. CPR was initiated based on conflicting code status orders.
Deficiencies (2)
F 0678: The facility failed to ensure the code status was obtained from the legal representative and the medical record included accurate advance directives. Conflicting orders directed both DNR and full code status, resulting in confusion during a medical emergency.
F 0842: The facility failed to ensure the medical record was complete and accurate, including failure to document notification of the responsible party after Resident #1's death.
Report Facts
Brief Interview Mental Status (BIMS) score: 7
CPR duration: 25
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Mar 19, 2025
Visit Reason
Unannounced visits were made to Autumn Lake Healthcare at Norwalk for the purpose of conducting an investigation related to complaint #43969.
Complaint Details
Complaint #43969 triggered the investigation. The complaint involved issues with advance directives, physician orders, and medical record documentation related to Resident #1.
Findings
The facility failed to ensure accurate and consistent advance directives and code status documentation for Resident #1, including failure to obtain code status from the legal representative, undated physician orders, and incomplete medical record documentation regarding notification of change in condition. These deficiencies contributed to confusion during a medical emergency and incomplete documentation of family notification after the resident's death.
Deficiencies (3)
Failed to ensure the code status was obtained from the legal representative and the medical record included accurate advance directives.
Failed to ensure physician orders were dated when signed.
Failed to ensure the medical record was complete and accurate, including notification of the responsible party of a change in condition.
Report Facts
Brief Interview Mental Status (BIMS) score: 7
Dates related to Resident #1: Conservator of Person effective date 2018-06-11; Advanced Directives dated 2023-10-14; Physician admission order dated 2024-06-20; MDS dated 2024-10-21; Resident Care Plan dated 2024-11-07; Physician order dated 2024-12-01; Nursing note dated 2025-01-13.
Plan of Correction compliance date: Compliance date for all violations is 2025-04-16.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maureen Golas Markure | Supervising Nurse Consultant | Signed the notice letter and responsible for communication regarding violations. |
| Adrian Thomas | Administrator | Named as facility administrator and involved in interviews regarding findings. |
| RN #1 | Day shift unit manager | Interviewed regarding code status confusion and notification of death. |
| RN #2 | Night supervisor | Interviewed regarding code blue response and documentation of notification. |
| RN #4 | Regional Nurse | Interviewed about undated physician orders. |
| APRN #1 | Advanced Practice Registered Nurse | Interviewed about not dating physician orders when signed. |
Inspection Report
Monitoring
Census: 135
Capacity: 150
Deficiencies: 1
Date: Sep 26, 2024
Visit Reason
A desk audit was completed to review the implementation of the Plan of Correction for the violation letter.
Findings
Violations #1 and #2 were identified as corrected as of 9/26/2024. The Plan of Correction was accepted and found in compliance. No additional findings were identified.
Deficiencies (1)
Violations #1 and #2 identified corrected as of 9/26/2024
Report Facts
Licensed Bed Capacity: 150
Census: 135
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Adrian Thomas | Administrator | Contacted regarding Plan of Correction compliance |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Aug 13, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to properly notify the discharging facility about the denial of readmission for a resident following hospitalization.
Complaint Details
The complaint investigation found that the facility denied readmission to Resident #2 without timely notification to the discharging hospital. The denial was not documented in the medical record, and the facility could not provide evidence of communication with the hospital regarding the refusal to readmit.
Findings
The facility failed to timely notify the discharging hospital that they would not readmit Resident #2 following hospitalization. Additionally, the facility did not maintain complete and accurate medical records documenting the readmission denial or communication with the hospital.
Deficiencies (2)
F 0622: The facility failed to notify the discharging facility timely that they would not readmit Resident #2 following hospitalization. The denial of readmission was not communicated prior to the resident's arrival.
F 0842: The facility failed to ensure a complete and accurate medical record regarding documentation of readmission or refusal to readmit Resident #2. No documentation of communication with the hospital about the refusal was provided.
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Aug 13, 2024
Visit Reason
An unannounced visit was conducted to Autumn Lake Healthcare At Norwalk on August 13, 2024, by the Department of Public Health for the purpose of conducting a complaint investigation survey.
Complaint Details
The visit was complaint-related with complaints numbered #36685 and #40145. The investigation found substantiated violations related to communication and documentation failures concerning readmission of Resident #2.
Findings
The facility failed to timely notify the discharging hospital that they would not readmit a resident following hospitalization and failed to ensure complete and accurate documentation regarding readmission or refusal to readmit a resident. Interviews and record reviews confirmed lack of communication and documentation related to the refusal to readmit Resident #2.
Deficiencies (2)
Failure to notify the discharging facility timely that they would not readmit the resident following hospitalization.
Failure to ensure a complete and accurate record including documentation regarding a readmission or refusal to readmit a resident.
Report Facts
Plan of Correction submission deadline: 2024
Date of Compliance: 2024
Audit frequency: 4
Audit frequency: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Adrian Thomas | Administrator | Named in interviews regarding denial of readmission and communication failures |
| Maureen Golas Markure | Supervising Nurse Consultant | Author of the inspection report and contact for questions regarding violations |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Aug 13, 2024
Visit Reason
An unannounced visit was conducted to Autumn Lake Healthcare At Norwalk for the purpose of a complaint investigation survey.
Complaint Details
The visit was complaint-related with complaints #36685 and #40145. The investigation found substantiated deficiencies related to communication and documentation failures concerning readmission of a resident.
Findings
The facility failed to timely notify the discharging hospital that they would not readmit a resident following hospitalization and failed to ensure complete and accurate documentation regarding readmission or refusal to readmit a resident. Interviews and record reviews confirmed lack of communication and documentation related to the denial of readmission for Resident #2.
Deficiencies (2)
Failed to notify the discharging facility timely that they would not readmit the resident following hospitalization.
Failed to ensure a complete and accurate record including documentation regarding a readmission or refusal to readmit a resident.
Report Facts
Plan of correction submission deadline: Sep 26, 2024
Date of compliance: Sep 21, 2024
Residents reviewed for discharge: 3
Resident readmission date: Nov 27, 2023
Resident discharge date: Oct 30, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Adrian Thomas | Administrator | Named in interviews regarding denial of readmission and communication failures. |
| Maureen Golas Markure | Supervising Nurse Consultant | Author of the inspection report and contact for questions regarding violations. |
Inspection Report
Renewal
Census: 140
Capacity: 150
Deficiencies: 0
Date: Jul 24, 2024
Visit Reason
The inspection was conducted as a licensing inspection with a renewal purpose, including review of complaint investigations identified by numbers CT37423, CT33799, CT33761, and CT40065.
Complaint Details
Complaint investigations referenced by numbers CT37423, CT33799, CT33761, and CT40065 were reviewed during the inspection.
Findings
The report indicates that violations of the General Statutes of Connecticut and/or regulations were reviewed, with attached violation letters referenced. The certification file was also reviewed as part of the inspection process.
Report Facts
Licensed Bed Capacity: 150
Census: 140
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dana Lemay | Personnel contacted during inspection | |
| Marie Mathieu | Survey Team Leader / Supervisor | Supervisor and report submitter |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jul 23, 2024
Visit Reason
The inspection was conducted to investigate multiple complaints regarding inadequate care and supervision at Autumn Lake Healthcare at Norwalk, including failure to follow physician orders for resident care, inadequate supervision to prevent falls and elopement, and failure to enforce the facility's non-smoking policy.
Complaint Details
The investigation was complaint-driven based on allegations of inadequate care and supervision, including failure to follow physician orders, inadequate fall prevention, failure to enforce non-smoking policies, and inadequate supervision to prevent elopement. The complaints were substantiated with multiple findings of minimal harm or potential for harm.
Findings
The facility failed to ensure proper air mattress settings per physician orders for Resident #23 and failed to ensure Resident #94 wore a prescribed helmet. The facility did not maintain adequate supervision for residents in the fall prevention program and failed to prevent Resident #97 from smoking and possessing contraband. Resident #111's falls were not properly addressed with revised care plans or interventions. Resident #27, at risk for wandering, was found outside unattended despite wearing a wander guard alarm.
Deficiencies (2)
F 0684: The facility failed to set the air mattress to Resident #23's weight as ordered and failed to ensure Resident #94 wore a helmet as recommended by a neurosurgeon when out of bed.
F 0689: The facility failed to provide adequate supervision to prevent accidents and ensure safety for multiple residents, including failure to supervise residents in the fall prevention program, failure to prevent Resident #97 from smoking and possessing contraband, failure to revise interventions after Resident #111's falls, and failure to prevent Resident #27 from wandering outside unattended despite a wander guard alarm.
Report Facts
Resident weights: 158.8
Number of residents in fall program: 9
Number of falls: 5
Distance: 92
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NA #2 | Nurse Aide | Named in finding for inadequate supervision during fall prevention program; observed with eyes closed while supervising residents |
| LPN #6 | Unit Manager | Responsible for ensuring air mattress settings were correct for Resident #23 |
| DNS | Director of Nursing Services | Interviewed regarding failures in supervision, care plans, and policy enforcement |
| SW #1 | Director of Social Services | Involved in discussions and education regarding Resident #97's smoking and contraband issues |
| LPN #1 | Licensed Practical Nurse | Observed Resident #27 outside and accompanied resident during wandering incident |
| NA #3 | Nurse Aide | Left Resident #27 unattended outside and was notified by receptionist |
| Receptionist | Observed Resident #27 outside and reported wandering incident |
Inspection Report
Routine
Deficiencies: 18
Date: Jul 23, 2024
Visit Reason
Routine inspection of Autumn Lake Healthcare at Norwalk to assess compliance with healthcare regulations including resident care, safety, and facility conditions.
Findings
The facility had multiple deficiencies including failure to honor hospice provider choice, inadequate management of resident personal funds, incomplete advance directive documentation, failure to notify physician of significant changes, unsafe environment conditions, incomplete PASARR screenings and notifications, incomplete care plans, inadequate fall prevention supervision, failure to administer PRN pain medication timely, inconsistent controlled drug counts, improper food preparation, and improper PPE storage.
Deficiencies (18)
F 0553: Facility failed to honor resident's choice of hospice provider and restricted hospice agency options despite resident and representative requests.
F 0567: Facility failed to ensure resident had reasonable access to personal funds and did not provide quarterly statements as required.
F 0568: Facility failed to properly hold, secure, and manage resident's personal money, including accounting discrepancies and lack of quarterly statements.
F 0578: Facility failed to obtain timely code status and advance directive documentation for residents after admission.
F 0580: Facility failed to notify physician of a mild anterior displacement of resident's shoulder after hospital return and lacked documentation of notification.
F 0584: Facility failed to maintain a safe, clean, comfortable, and homelike environment and failed to keep resident's personal property safe from loss.
F 0645: Facility failed to complete PASARR rescreen within required timeframe for resident with serious mental illness.
F 0646: Facility failed to notify state mental health authority of significant changes in residents' mental health diagnoses.
F 0656: Facility failed to develop a comprehensive care plan for a resident with dementia including goals and interventions.
F 0657: Facility failed to invite resident and representative to care conferences and failed to hold timely care conferences.
F 0658: Facility failed to ensure RN assessments after falls, neurological assessments, and proper documentation of falls and bruises.
F 0684: Facility failed to set air mattress to resident's weight per physician order and failed to consistently apply recommended helmet for resident out of bed.
F 0686: Facility failed to complete Braden Scale and weekly skin assessments per physician order and failed to document RN assessment upon new pressure ulcer identification.
F 0689: Facility failed to provide adequate supervision during fall prevention program, failed to supervise resident with contraband smoking materials, and failed to prevent elopement of a wander risk resident.
F 0697: Facility failed to administer PRN pain medication when resident requested and failed to follow up on pain management needs.
F 0755: Facility failed to ensure shift-to-shift controlled drug counts were consistently completed and signed by nurses.
F 0812: Facility failed to prepare food under sanitary conditions, including thawing chicken in a dirty three-compartment sink without gloves.
F 0880: Facility failed to store personal protective equipment in a sanitary manner; PPE was stored on the floor of an isolation cart.
Report Facts
Missing controlled drug count signatures: 11
Missing controlled drug count signatures: 8
Resident weight: 158.8
Resident weight: 260
Resident weight: 180
Hydromorphone PRN dose gap: 17.5
Pressure ulcer measurement: 7.2
Pressure ulcer measurement: 3
Pressure ulcer measurement: 0.2
Pressure ulcer measurement: 4.5
Pressure ulcer measurement: 2
Pressure ulcer measurement: 0.2
Pressure ulcer measurement: 3
Pressure ulcer measurement: 5.2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #6 | Unit Manager | Named in fall assessment and neurological assessment documentation for Resident #6 fall |
| SW #1 | Director of Social Services | Named in hospice provider contract discussion and smoking policy enforcement |
| DNS | Director of Nursing Services | Named in multiple interviews regarding fall assessments, pain management, controlled drug counts, and supervision |
| ADNS | Assistant Director of Nursing Services | Named in multiple interviews regarding fall assessments, pain management, controlled drug counts, and supervision |
| LPN #7 | Named in failure to administer PRN pain medication to Resident #42 | |
| LPN #2 | Named in fall assessments and neurological assessments for Resident #112 | |
| RN #3 | Corporate Clinical RN | Named in fall assessment and bruise assessment interviews |
| NA #2 | Nurse Aide | Named in fall program supervision failure |
| LPN #5 | Named in fall program supervision failure observation | |
| NA #3 | Nurse Aide | Named in elopement supervision failure |
| LPN #1 | Named in elopement supervision failure | |
| Director of Recreational Therapy | Named in smoking incident observation and reporting | |
| LPN #9 | Named in PRN pain medication interview | |
| RN #2 | Named in PRN pain medication interview | |
| LPN #12 | Named in controlled drugs count interview | |
| [NAME] #1 | Kitchen Staff | Named in food preparation observation and interview |
| LPN #3 | Named in PPE storage observation |
Inspection Report
Plan of Correction
Census: 137
Capacity: 150
Deficiencies: 0
Date: May 30, 2024
Visit Reason
A desk audit was conducted to review the implementation of the Plan of Correction for a prior violation letter dated 4/11/24.
Findings
The desk audit found that Violation #1 was corrected as of 5/30/24. The administrator and director of nursing confirmed via telephone that all violations were corrected.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Adrian Thomas | Administrator | Contacted during the desk audit and confirmed correction of violations. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Apr 11, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding an alleged resident-to-resident physical altercation involving Resident #1 and Resident #2 on 2024-02-22.
Complaint Details
The complaint involved an alleged physical altercation between Resident #1 and Resident #2 on 2/22/2024. The allegation was investigated through staff and resident interviews, assessments, and review of documentation. The allegation was not substantiated as Resident #2 had no injuries and denied being punched. Resident #1 was assessed and found not to be a danger to self or others.
Findings
The facility failed to develop and implement a complete care plan with specific interventions to monitor Resident #1's aggressive behavior following the alleged altercation. The investigation found no physical injury to Resident #2 and the allegation of abuse was not substantiated.
Deficiencies (1)
F 0656: Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. The facility failed to specify how Resident #1 would be monitored for safety following an alleged physical altercation with another resident.
Report Facts
Date of alleged incident: Feb 22, 2024
Date of survey completion: Apr 11, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Reported and documented the alleged resident altercation and observations |
| APRN #1 | Advanced Practice Registered Nurse | Assessed Resident #1 following the incident and adjusted medication |
| MD #2 | Physician | Evaluated Resident #1 for assaultive behavior and ordered emergency psychiatric evaluation |
| DNS | Director of Nursing Services | Interviewed regarding care plan and monitoring following the incident |
| SW #1 | Social Worker | Conducted interviews with residents regarding the alleged incident |
Inspection Report
Complaint Investigation
Census: 128
Capacity: 150
Deficiencies: 0
Date: Nov 10, 2022
Visit Reason
The inspection visit was conducted as a complaint investigation related to Complaint Investigation # CT 00033246.
Complaint Details
Complaint Investigation # CT 00033246 was the reason for the visit. No violations were found during the 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.
Report Facts
Licensed Bed/Bassinet Capacity: 150
Census: 128
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Adrian Thomas | Administrator | Personnel contacted during the inspection |
| Isabela Grabarz | DNS | Personnel contacted during the inspection |
Inspection Report
Follow-Up
Census: 122
Capacity: 150
Deficiencies: 0
Date: Mar 9, 2022
Visit Reason
A desk audit was conducted on 03/08/2022 and 03/09/2022 for the purpose of reviewing the Plan of Correction (POC) for the violation letter dated 02/07/2022.
Findings
Violations 1, 2, 3, and 4 had been corrected and no violations were identified at the time of this desk audit. The facility is in compliance with all regulations surveyed.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| James Tan | RN, Nurse Consultant | Conducted the desk audit and submitted the report. |
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Nov 23, 2021
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements related to resident care, including resident rights, care planning, restorative ambulation, splint application, and oxygen therapy.
Findings
The facility failed to accommodate a resident's shower preferences due to staffing shortages, failed to revise care plans for splint application and oxygen therapy, did not ensure restorative ambulation per physician orders, and lacked physician orders for oxygen and Bipap therapy maintenance. Documentation and communication deficiencies were also noted.
Deficiencies (4)
F 0561: The facility failed to accommodate Resident #38's preferences regarding scheduled showers, providing only 1 of 9 scheduled showers in October and none in November. Documentation of shower refusals was also lacking.
F 0657: The facility failed to revise care plans for Resident #38's right hand/wrist splint and KAFO splint and for Resident #83's oxygen therapy. Splints were not applied as ordered and physician orders were not properly entered for nursing awareness.
F 0684: The facility failed to ensure restorative ambulation for Resident #33 per physician order to ambulate up to 150 feet with assistance. Documentation of ambulation attempts and refusals was inadequate.
F 0695: The facility failed to obtain physician orders for oxygen therapy and maintenance of oxygen and Bipap tubing for Resident #83. Orders were subsequently obtained after surveyor inquiry.
Report Facts
Scheduled showers received: 1
Scheduled showers received: 0
Ambulation distance: 150
Oxygen flow rate: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #2 | Registered Nurse | Indicated splint order issues and lack of documentation for Resident #38 |
| DNS | Director of Nursing Services | Provided information on shower documentation, care plan responsibilities, and oxygen therapy orders |
| NA #2 | Nursing Assistant | Reported staffing shortages affecting shower provision for Resident #38 |
| RN #1 | Registered Nurse | Obtained physician orders for Resident #83 oxygen and Bipap therapy after surveyor inquiry |
| DOR #1 | Director of Rehabilitation | Discussed splint application responsibilities and restorative ambulation expectations |
| NA #1 | Nursing Assistant | Unaware of ambulation order for Resident #33 and documentation procedures |
| ADNS | Assistant Director of Nursing Services | Discussed documentation expectations for ambulation and nursing assistant documentation issues |
Inspection Report
Renewal
Census: 115
Capacity: 150
Deficiencies: 0
Date: Nov 23, 2021
Visit Reason
The inspection was conducted as a renewal licensing inspection for the facility.
Findings
No violations of the General Statutes of Connecticut or regulations were identified at the time of this inspection.
Inspection Report
Routine
Census: 86
Capacity: 150
Deficiencies: 0
Date: May 3, 2020
Visit Reason
An unannounced visit was made by a representative of the Facility Licensing and Investigation Section on 5/3/20 for the purpose of conducting a COVID-19 survey.
Findings
Staffing was reviewed for 5/3/20 and met the minimum requirements of the regulations of the State Agency. Based on a tour of the facility, review of facility documentation and interviews, no findings were identified during this visit.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lorraine Brooks-Williams | RN/DPV | Personnel contacted during the COVID-19 survey visit |
| Meghan Smith | Administrator | Personnel contacted during the COVID-19 survey visit |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jan 14, 2020
Visit Reason
The document is a Plan of Correction responding to a violation related to Resident #1's care, specifically addressing dehydration and fluid imbalance risks.
Findings
Resident #1 had multiple health issues including dementia and was at risk for dehydration. The care plan failed to adequately monitor and address dehydration risks despite identified nutritional problems and lab results indicating worsening dehydration. Resident #1 was discharged prior to reassessment.
Deficiencies (1)
Care plan failed to reflect interventions and goals directed to monitoring the resident for dehydration.
Report Facts
Date of compliance: Feb 21, 2020
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding Resident #1's risk for dehydration and care plan |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed regarding Resident #1's risk for dehydration and care plan |
Inspection Report
Renewal
Census: 242
Capacity: 282
Deficiencies: 9
Date: Jun 11, 2019
Visit Reason
The inspection was conducted as a licensure renewal inspection and certification survey for Autumn Lake Healthcare at New Britain.
Findings
Multiple violations of the Connecticut General Statutes and regulations were identified during the inspection, including deficiencies in medical records, care planning, medication administration, infection control, and facility maintenance. Plans of correction were submitted to address these issues.
Deficiencies (9)
Failure to ensure care plans were revised to prevent injury related to behaviors.
Failure to ensure discharge planning was adequate and medical equipment was properly evaluated.
Failure to ensure behaviors were addressed to prevent falls and injuries.
Failure to monitor respiratory status and obtain daily weights as ordered.
Failure to ensure pain management and medication administration were properly documented and monitored.
Failure to ensure proper documentation and investigation of alleged abuse.
Failure to ensure infection control practices, including PPE use and medication administration, were followed.
Failure to ensure proper documentation of transfers and medical records.
Failure to ensure facility maintenance and environmental safety standards were met.
Report Facts
Licensed Bed Capacity: 282
Census: 242
Inspection Dates: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joshua Schechter | Administrator | Named as personnel contacted and author of plan of correction cover letter. |
| Judy Birtwistle | Supervising Nurse Consultant | Signed multiple reports and notices related to the inspection. |
| Karen Gworek | Supervising Nurse Consultant | Signed complaint investigation related documents. |
| Megan Smith | Administrator | Personnel contacted during complaint investigation. |
| Michelle Morrison | DON | Personnel contacted during complaint investigation. |
Inspection Report
Annual Inspection
Deficiencies: 2
Date: May 31, 2019
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements for nursing home care and facility operations.
Findings
The facility failed to develop a care plan addressing a resident's behavior of removing dentures, leading to potential loss. Additionally, the facility did not ensure kitchen staff maintained proper sanitizing solution concentrations for food preparation surfaces.
Deficiencies (2)
F 0657: The facility failed to initiate a care plan related to denture care and placement after meals for a resident who repeatedly removed dentures and placed them in random locations.
F 0801: The facility failed to ensure kitchen staff maintained the sanitizing solution at or above 200 ppm as required, due to use of incorrect test strips and lack of manufacturer guidelines.
Report Facts
Sanitizing solution concentration: 200
Date of grievance: Feb 6, 2019
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Aide (NA) #4 | Reported resident removed dentures after meals | |
| Licensed Practical Nurse (LPN) #4 | Aware of resident's denture removal behavior and discussed with unit manager | |
| Registered Nurse (RN) #5 | Unit manager aware of denture removal behavior and care plan omission | |
| Food Service Director | Identified issues with sanitizing solution concentration and test strip usage | |
| Sales Manager #2 | Provided information on sanitizing test strip manufacturer guidelines |
Inspection Report
Plan of Correction
Deficiencies: 3
Date: May 31, 2019
Visit Reason
Unannounced visits were made to Autumn Lake Healthcare At Norwalk to conduct multiple investigations, a licensure renewal inspection, and a certification survey based on information received through May 28, 2019.
Complaint Details
Complaints #25172 and #24939 triggered the investigations and inspection.
Findings
The facility was found noncompliant with Connecticut state regulations in three areas: failure to initiate a care plan related to denture care for a resident, failure to maintain appropriate sanitizing solution concentrations in the kitchen, and failure to report an incident involving a resident with a call bell cord wrapped around their neck. Plans of correction were submitted addressing these issues.
Deficiencies (3)
Failure to initiate a care plan related to denture care and placement after meals for Resident #58.
Failure to ensure kitchen staff maintained sanitizing solution at appropriate concentration levels and lacked competency in sanitizing procedures.
Failure to report an incident involving Resident #175 found with a call bell cord wrapped around their neck to the state agency as required.
Report Facts
Completion date for plan of correction: Jul 10, 2019
Number of sampled residents reviewed for denture care deficiency: 3
Sanitizing solution concentration: 200
Audit frequency for denture care plans: 4
Audit frequency for sanitizing solution PPM log: 4
Audit frequency for classification of reportable events: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Norma Schuberth | R.N. | Signed the notice letter as Supervising Nurse Consultant. |
| Megan Smith | Administrator | Recipient of the notice letter. |
Inspection Report
Complaint Investigation
Census: 135
Capacity: 150
Deficiencies: 5
Date: Apr 10, 2018
Visit Reason
The inspection was conducted as a complaint investigation combined with a licensing and certification inspection at Autumn Lake Healthcare At Norwalk during unannounced visits on April 10, 11, 12, 16, and 17, 2018.
Complaint Details
Complaint investigation #22937 was conducted. The complaint involved allegations of mistreatment and failure to follow proper care procedures. The investigation substantiated issues related to resident dignity and care practices.
Findings
The facility was found noncompliant with several regulations including failure to ensure dignified treatment of a resident, incorrect coding of PASRR assessments, inadequate self-administration medication practices, improper food handling by dietary staff, and failure to maintain appropriate infection control practices during wound care.
Deficiencies (5)
Failure to ensure resident was treated in a dignified manner; NA #1 spoke rudely and slammed door when resident requested assistance.
Failure to code the MDS assessment correctly related to PASRR for Resident #111.
Failure to ensure self-medication administration practices were completed in accordance with facility policy and procedure for Resident #118.
Dietary staff handled food without proper hand hygiene and cross contamination prevention.
Failure to maintain appropriate infection control practices during dressing change for Resident #333.
Report Facts
Licensed Bed Capacity: 150
Census: 135
Inspection Dates: 5
Number of OTC medication containers: 10
Number of residents reviewed for PASRR: 5
Number of residents reviewed for infection control: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joshua Schechter | Administrator | Named as facility administrator and signer of plan of correction |
| Michelle Morrison | Director of Nursing Services (DNS) | Contacted personnel and interviewed regarding allegations and findings |
| Kim Hriceniak | Public Health Services Manager | Signed violation letters and correspondence related to inspection |
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