Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Autumn Lake Healthcare At Bucks Hill during CMS and state inspections, most recent first.
The facility failed to maintain dishwasher temperatures according to the manufacturer's requirements, resulting in inadequate sanitization of dishware. Observations showed wash and rinse cycle temperatures below the required minimums, and logs confirmed this was a common issue. The dietary aide did not follow policy to stop washing and alert a manager when temperatures were inadequate.
The facility failed to serve food at safe and appetizing temperatures, as evidenced by resident complaints and a test tray observation. Residents reported cold soup and coffee, and a test tray showed food temperatures below required standards. The Food Service Director confirmed the deficiency, acknowledging that the temperatures did not meet policy requirements.
A resident with Huntington's disease and dysphagia had a dietary request to consume all food through a straw, which was not honored by the facility. The resident was on a pureed diet with honey thickened liquids, and the request was not reviewed due to the absence of a full-time speech therapist. The facility prioritized safe care over preferences, as determined by the speech therapist, and the Dietician later identified a blended puree as a potential solution.
A facility failed to ensure a resident's advance directives were signed and available, leading to a discrepancy between the hospital's DNR/DNI status and the facility's full code status. The responsible party was not contacted upon admission, and the facility defaulted to a full code without verifying the resident's wishes.
A resident's gold bracelet went missing, and the facility failed to report the loss to the State Agency within the required 24-hour period. Despite searching and interviewing staff, the bracelet was not found. The facility's policies lacked clear actions for missing items, and the required reporting was not completed.
A resident with severe cognitive impairment and multiple diagnoses experienced a decline in transfer and ambulation abilities due to the facility's failure to follow a physician's order for regular ambulation. Despite a care plan requiring ambulation with assistance, documentation showed numerous missed opportunities for walking. Staff interviews revealed a lack of communication and action regarding the resident's decline, with the rehabilitation team not being informed or conducting timely evaluations.
A resident with a history of CVA and other conditions was found with soiled and lengthy fingernails, despite being dependent on staff for personal hygiene. Observations over several days confirmed the deficiency, and staff interviews revealed that nail care was not performed due to time constraints, contrary to the facility's policy and care plan requirements.
A facility failed to follow hospital discharge orders for a resident with end-stage renal disease, delaying a nephrology consultation by over three months. The resident was unaware of the need for a timely follow-up, and the APRN did not prioritize the consultation, despite the resident experiencing a hypotensive episode.
A facility failed to conduct weekly skin checks and RN assessments for a resident with a stage 4 pressure ulcer, as per physician orders. The resident, who was severely cognitively impaired, had a care plan that included weekly skin checks on shower days, but these were not completed for several months. Upon readmission, the resident's pressure ulcer was not assessed by an RN, and the LPN's assessment lacked necessary documentation. This deficiency highlights a failure to adhere to the facility's policy for pressure ulcer monitoring and documentation.
A resident with a history of CVA and contracture was not consistently provided with a left-hand splint as ordered, due to discrepancies between physician orders and EHR instructions. Observations showed the resident without the splint during prescribed times, and staff interviews revealed a transcription error in the EHR. The facility's policy required monitoring of care plan interventions, which was not followed.
The facility failed to monitor and document the weights of two residents, leading to deficiencies in their nutritional care. One resident experienced significant weight loss without proper re-evaluation, while another was not weighed upon admission due to a broken scale. Staff interviews revealed a lack of adherence to the facility's weight assessment policy.
The facility failed to ensure proper PPE use during high contact care for two residents requiring Enhanced Barrier Precautions (EBP). One resident with chronic wounds and another with a stage 3 pressure ulcer were not provided care with the necessary gown and gloves, despite clear signage and facility policy. Staff admitted to either rushing or forgetting to wear PPE.
The facility failed to maintain a homelike, sanitary, and safe environment in a tub room on the [NAME] Unit. Observations revealed cracked tiles, stained radiators, a damaged vanity cabinet, and debris on the fan. The Maintenance Director acknowledged these issues but was unsure about the last cleaning of the fan. The Administrator was uncertain about remodeling plans for the unit, and the Environmental Rounds log did not document these concerns.
The facility failed to notify the POA for a resident with Alzheimer's and various eye conditions when the resident experienced a change in condition and new treatments were recommended. Despite the facility's policy, the POA was not informed when artificial tears, Erythromycin, and various blood tests were ordered. Interviews confirmed that the POA should have been notified with every new order, but this did not occur.
A facility failed to conduct and document an initial wound assessment for a resident with potential skin integrity impairment, despite the care plan's directives and the facility's Skin Assessment policy. Interviews confirmed that the responsible nurse did not complete the necessary assessment and documentation.
The facility failed to conduct and document weekly skin assessments for a resident with conditions such as Alzheimer's dementia and chronic kidney disease, despite a physician's order and care plan indicating the need for such assessments. The Nursing Supervisor confirmed the lapse, and no policy was provided.
The facility failed to follow a physician's order to obtain laboratory blood work for a resident with multiple comorbidities, including Alzheimer's dementia and chronic kidney disease. Despite the care plan identifying a risk for dehydration and the physician's order for a repeat Basic Metabolic Panel, the required blood work was not obtained. Interviews revealed that the process for obtaining the blood work was not followed, and the facility staff could not locate the blood work reports.
Dishwasher Temperature Deficiency
Penalty
Summary
The facility failed to maintain dishwasher temperatures according to the manufacturer's requirements, resulting in inadequate sanitization of dishware. During an observation of the dishwashing process, the wash cycle temperature was recorded at 148 degrees Fahrenheit and the rinse cycle at 150 degrees Fahrenheit, both below the required minimums of 160 degrees Fahrenheit for the wash cycle and 180 degrees Fahrenheit for the rinse cycle. Despite multiple attempts to reach the required temperatures, the wash cycle never met the necessary minimum, indicating a failure to ensure proper hot water sanitization. Further investigation revealed that the dishwasher temperature logs consistently recorded temperatures below the required minimums, and the dietary aide admitted to not following the facility policy, which required stopping the washing process and alerting a manager if temperatures were inadequate. The Director of Food Services acknowledged that the current and previous two loads of dishes could not be considered adequately sanitized due to the failure to meet temperature requirements. The facility's ware washing policy emphasized the importance of maintaining dish machine water temperatures in accordance with the manufacturer's recommendations, which was not adhered to in this instance.
Failure to Serve Food at Safe Temperatures
Penalty
Summary
The facility failed to ensure that resident food was served at a safe and appetizing temperature, as evidenced by multiple complaints and observations. During the Food Committee Meetings in October and November, residents reported that their soup and coffee were often served cold. An interview with Resident Council attendees further confirmed that food was not served at a safe and appetizing temperature approximately 50% of the time. This issue was corroborated by a test tray observation conducted on December 5th, where the food temperatures were found to be below the required standards. During the observation, dietary staff prepared to plate food with the steam tray temperature initially at 150 degrees Fahrenheit. However, by the time the test tray was delivered and checked, the temperatures of the pork chops, mashed potatoes, and hot beets were significantly below the goal of 135 degrees Fahrenheit, and the milk was above the goal of 41 degrees Fahrenheit. The Food Service Director acknowledged that the test tray temperatures did not meet the facility's policy requirements for food quality and palatability, indicating a failure to maintain appropriate food temperatures during service.
Failure to Honor Resident's Dietary Request
Penalty
Summary
The facility failed to honor a dietary request for a resident with Huntington's disease, severe protein-calorie malnutrition, and dysphagia. The resident was on a pureed diet with honey thickened liquids, as per a medical doctor's order. Despite a speech therapy progress note indicating no signs of aspiration on this diet, the resident's responsible party requested that all food be consumed through a straw, which was not honored. The Director of Nursing Services acknowledged the request but emphasized the facility's obligation to prioritize safe care over preferences, as determined by the speech therapist. The facility lacked a full-time speech therapist, relying instead on per-diem therapists who did not follow residents as part of their caseload. The Dietician was aware of the request for dietary consistency accommodations but was initially unaware of the specific request for all meals to be in liquid form. Upon further consultation, the Dietician learned that a blended puree could meet the request, often used for hospice patients for comfort and quality of life. The facility's policies on weight assessment and advanced directives emphasized consideration of end-of-life decisions, but the dietary request was not initially reviewed or accommodated.
Failure to Obtain Signed Advance Directives
Penalty
Summary
The facility failed to ensure that the advance directives consent for a resident, who had a history of traumatic brain injury and epilepsy, was signed and available. The resident was admitted with a hospital transfer summary indicating a DNR/DNI status, but the facility's physician order and care plan listed the resident as a full code, requiring CPR. The facility's policy required obtaining a code status within 24 hours of admission, but the advance directive form remained unsigned due to the unavailability of the resident's responsible party. Interviews with the Director of Nurses and APRN revealed that the facility defaulted to a full code status in the absence of a signed advance directive, despite the resident's discharge status from the hospital. The responsible party was not contacted upon admission to verify the resident's code status, and the facility did not follow up with the responsible party to confirm the resident's wishes. The advance directives paperwork was eventually signed after surveyor inquiry, but initially, the facility did not adhere to its policy of reviewing and obtaining signatures for advance directives upon admission.
Failure to Report Missing Resident Property
Penalty
Summary
The facility failed to report the loss of a resident's personal belonging to the State Agency within the required 24-hour timeframe. The incident involved a resident diagnosed with Huntington's disease, major depressive disorder, and bilateral cataracts, who was dependent on assistance for daily activities. The resident's family reported the loss of a 14 Karat gold bracelet, which was engraved with security information. Despite the facility's efforts to search for the bracelet and interview staff, the item was not found. The facility's Administrator was aware of the loss but did not report it to the State Agency, as there was no evidence of theft. The facility's policies on resident personal belongings and abuse were reviewed, revealing a lack of specific actions to be taken when an item is identified as missing. The facility's abuse policy required reporting misappropriation of resident property to the State Agency and law enforcement within 24 hours, with a follow-up report within 72 hours. However, the facility did not adhere to this policy, as the loss of the bracelet was not reported within the stipulated time frame.
Failure to Prevent Decline in Resident's ADL Abilities
Penalty
Summary
The facility failed to prevent a decline in the ability of Resident #44 to perform activities of daily living, specifically in transfer and ambulation abilities. Resident #44, who has diagnoses including atrial fibrillation, repeated falls, and Alzheimer's disease, was identified in a quarterly Minimum Data Set (MDS) assessment as having severe cognitive impairment and requiring substantial assistance for transfers and ambulation. Despite a physician's order to ambulate the resident twice a day to prevent functional decline, documentation revealed that the resident rarely walked in the hallway and had numerous missed opportunities for ambulation over several months. Interviews with staff revealed a lack of communication and action regarding the resident's decline. A nurse aide noted the resident's increased need for assistance but did not report it, and a licensed practical nurse was unaware of the resident's inability to ambulate as per the care plan. The rehabilitation director and physical therapist were not informed of the resident's decline and had not conducted a recent evaluation. This lack of communication and failure to follow the care plan contributed to the resident's decline in ambulation and transfer abilities.
Failure to Maintain Proper Nail Care for a Resident
Penalty
Summary
The facility failed to maintain proper nail care for a resident diagnosed with cerebral vascular accident (CVA), joint derangement, contracture, and left flaccid hemiplegia. The resident, who had intact cognition, was dependent on staff for personal hygiene and dressing. The care plan specified that nail care should be performed on bath days, and a physician's order required a body audit every week on shower day. However, observations over several days revealed that the resident's fingernails were soiled with brownish debris and were abnormally lengthy. The resident expressed dissatisfaction with the length of their nails and indicated that they had not requested nail care because it was not their responsibility. Interviews with staff revealed that the resident had received a bath on a specified date, during which nail care should have been performed. However, the nurse aide responsible for the resident's care on subsequent days admitted to observing the long and soiled nails but did not address the issue due to being too busy. The Director of Nursing Services (DNS) confirmed that it was the responsibility of the nurse aide to cut and clean the resident's nails, with oversight from the nurse. The facility's policy on nail care required staff to review the care plan for any special needs and to ensure regular cleaning and trimming of nails, which was not adhered to in this case.
Failure to Follow Hospital Discharge Orders for Specialist Consultation
Penalty
Summary
The facility failed to adhere to a hospital discharge order for a resident who was supposed to follow up with a nephrologist within one week after discharge. The resident, who had diagnoses including end-stage renal disease, urinary tract infection, and heart failure, was discharged from the hospital with instructions to see a nephrologist. However, the clinical record showed that the resident did not have a nephrology consultation until more than three months later. During this period, the resident experienced a hypotensive episode, which further emphasized the need for timely specialist consultation. Interviews revealed that the resident was unaware of the discharge instructions and would have requested a timely consultation if informed. The APRN involved acknowledged the discharge instructions but did not prioritize the nephrology follow-up, considering it unnecessary. This oversight led to a significant delay in the resident receiving specialist care, contrary to the hospital's discharge recommendations.
Failure to Conduct Weekly Skin Checks and RN Assessment for Pressure Ulcer
Penalty
Summary
The facility failed to conduct weekly skin checks and assessments for a resident with a stage 4 pressure ulcer, as per physician orders. The resident, who was severely cognitively impaired and required assistance for bed mobility, had a care plan that included weekly skin checks on shower days. However, documentation revealed that these checks were not completed from April 7, 2023, to June 30, 2023. Additionally, upon readmission, the resident's pressure ulcer was not assessed by a Registered Nurse (RN) as required, and the Licensed Practical Nurse (LPN) who conducted the initial assessment failed to document measurements or describe the wound's appearance. The facility's policy required that pressure ulcer monitoring be completed by an RN or designee, with documentation of findings in the medical record. Despite this, the RN did not assess or document the pressure ulcer upon the resident's readmission, and the LPN's assessment was incomplete. Interviews with staff revealed a lack of clarity and adherence to the facility's practice of having RNs assess and document pressure ulcers, leading to a deficiency in the care provided to the resident.
Failure to Apply Hand Splint as Ordered
Penalty
Summary
The facility failed to apply a left wrist hand splint as ordered for a resident diagnosed with a Cerebral Vascular Accident (CVA), contracture of the left hand joint, and flaccid hemiplegia affecting the left dominant side. The resident's care plan required the use of a left wrist brace when out of bed and during transfers to prevent further contractures. However, observations on multiple occasions revealed that the resident was not wearing the left-hand splint as prescribed. Interviews with staff, including a nurse aide and a physical therapist, confirmed discrepancies between the physician's orders and the instructions in the electronic health record (EHR), leading to inconsistent application of the splint. The physician's order specified that the left-hand splint should be worn from 7:00 AM to 3:00 PM, but the EHR task section indicated different times for application and removal. This discrepancy was attributed to a transcription error by a former staff member. The nurse aide responsible for the resident's care followed the incorrect EHR instructions, applying the splint only for a couple of hours in the afternoon. The Director of Nurses acknowledged the inconsistency between the physician's orders and the EHR instructions. The facility's policy required nurses to monitor the consistent implementation of care plan interventions, which was not adhered to in this case.
Failure to Monitor and Document Resident Weights
Penalty
Summary
The facility failed to adequately monitor and address the nutritional needs of two residents, leading to deficiencies in their care. Resident #44, who had diagnoses including atrial fibrillation and Alzheimer's disease, experienced a significant weight loss of 6.4% over a short period. The facility did not weigh the resident monthly as required, did not reweigh the resident after the initial weight loss for accuracy, and failed to ensure the dietician re-evaluated the resident's nutritional needs despite a physician's order. The dietician was unaware of the facility's policy for addressing weight loss and did not complete a necessary nutritional assessment. Resident #281, who was newly admitted and diagnosed with dementia and severe sepsis, was not weighed upon admission as required. The facility's scale was reportedly broken, and the resident's weight was not documented until several days later, resulting in a discrepancy between the recorded weight and the actual weight. The dietician was not informed of the broken scale and was unable to make accurate nutritional recommendations due to the lack of an admission weight. The facility's policy required weights to be taken on admission and weekly thereafter, but this was not followed. Interviews with staff revealed a lack of awareness and adherence to the facility's weight assessment and intervention policy. Nursing assistants and licensed practical nurses were unsure why weights were not taken or documented, and the Director of Nursing Services was not informed of the broken scale. The facility's failure to follow its own policies and procedures for monitoring and documenting residents' weights contributed to the deficiencies in care for these residents.
Failure to Use PPE During High Contact Care for Residents on EBP
Penalty
Summary
The facility failed to ensure appropriate use of Personal Protective Equipment (PPE) during high contact care for two residents who required Enhanced Barrier Precautions (EBP). Resident #41, diagnosed with peripheral vascular disease, diabetes, and chronic kidney disease, had a physician's order for EBP due to chronic wounds. Despite visible signage and a cart with PPE outside the resident's room, NA #2 was observed providing high contact care without wearing the required gown and gloves. NA #2 admitted to rushing and being unaware of the facility policy, although the Director of Nursing stated that all staff had been educated on PPE use. Similarly, Resident #59, who had a stage 3 pressure ulcer and required maximal assistance, was also not provided care with the necessary PPE. NA #1 was observed bathing the resident and changing linens without wearing gloves and a gown, as required by the facility's EBP policy. NA #1 acknowledged forgetting to wear PPE despite being aware of the requirement. The facility's policy clearly stated that staff must wear gloves and a gown during high contact activities for residents on EBP, but this was not adhered to in these instances.
Deficiency in Tub Room Maintenance
Penalty
Summary
The facility failed to maintain a homelike, sanitary, and safe environment in one of its tub rooms on the [NAME] Unit. During an initial tour, it was observed that the tiles on the floor and walls were cracked and broken, the radiators were stained and discolored, and the vanity cabinet with the sink was damaged and discolored. Additionally, debris was noted hanging from the fan. An interview with the Maintenance Director revealed that he was aware of the issues, including the need for cleaning the fan, but was unsure when it was last cleaned. The Administrator was also uncertain about the remodeling plans for the [NAME] Unit. Furthermore, the Environmental Rounds log from September failed to identify any concerns with the tub rooms, indicating a lack of proper documentation and oversight.
Failure to Notify POA of Resident's Change in Condition and New Treatments
Penalty
Summary
The facility failed to notify the Power of Attorney (POA) for Resident #1 when the resident experienced a change in condition and new treatments were recommended. Resident #1, who had diagnoses including Alzheimer's dementia and various eye conditions, was noted to have poor decision-making skills and required extensive assistance with daily activities. Despite the facility's policy requiring notification of the resident's family or legal representative in such circumstances, the POA was not informed when artificial tears, Erythromycin, and various blood tests were ordered on different dates in August 2023. The deficiency was identified through clinical record reviews, facility documentation, and interviews. The Advanced Practice Registered Nurse (APRN) had documented changes in Resident #1's condition and recommended treatments, but there was no evidence that the POA was notified. Interviews with the Nursing Supervisor confirmed that the POA should have been notified with every new order, but this did not occur. The facility's Notification of Change policy explicitly directed that the resident's family member or legal representative must be informed of new treatments, which was not adhered to in this case.
Failure to Conduct Initial Wound Assessment
Penalty
Summary
The facility failed to conduct and document an initial wound assessment for a resident with potential skin integrity impairment. Resident #1, who had diagnoses including Alzheimer's dementia, acute kidney injury, chronic kidney disease, and heart failure, was identified as being at risk for pressure ulcers due to decreased mobility and incontinence. Despite the care plan's directives to monitor and document changes in skin status, the clinical record review revealed that no complete assessment, including size, color, and exact location of the blisters, was conducted when blisters were first identified on 9/1/23. This lack of documentation prevented the establishment of a baseline description necessary for further evaluation of the blisters' improvement or decline. Interviews with the wound nurse (LPN #1) and the 7AM-3PM Nursing Supervisor (RN #1) confirmed that the nurse who identified the new skin impairment was responsible for assessing and documenting it. However, LPN #1 could not explain why the initial assessment and measurements were not completed. The facility's Skin Assessment policy mandates that a licensed or registered nurse conduct a skin assessment upon admission, re-admission, change in condition, or identification of a new area, which was not adhered to in this case.
Failure to Conduct and Document Weekly Skin Assessments
Penalty
Summary
The facility failed to conduct and document weekly skin assessments for Resident #1, who had a potential for skin integrity impairment due to conditions such as Alzheimer's dementia, acute kidney injury, chronic kidney disease, and heart failure. A physician's order required a body audit on admission and daily for three days, followed by weekly assessments every Tuesday. The Resident Care Plan identified the resident as being at risk for pressure ulcers due to decreased mobility and incontinence, with specific interventions to monitor and document skin status. However, the clinical record showed that weekly skin checks were not conducted on multiple specified dates. An interview with the Nursing Supervisor confirmed the lapse in conducting and documenting the required assessments, and no weekly skin assessment policy was provided upon request.
Failure to Obtain Ordered Laboratory Blood Work
Penalty
Summary
The facility failed to follow the physician's order and obtain the laboratory blood work for a resident with multiple comorbidities, including Alzheimer's dementia, acute kidney injury, chronic kidney disease, and heart failure. The resident's care plan identified a risk for dehydration related to medication use, and interventions included obtaining laboratory blood work as ordered. Despite a physician's order to repeat a Basic Metabolic Panel (BMP) on a specific date, the facility did not obtain the required blood work. Interviews with the Administrator and the Nursing Supervisor revealed that the blood work was not drawn, and the facility staff was unsure where the copies of the drawn blood work were. The process for obtaining the blood work involved the APRN placing an order in the computer, the floor nurse or supervisor noting the order, filling the laboratory sheet, and placing it in the laboratory folder. However, the laboratory folder lacked documentation from the relevant month, and the facility staff could not locate the blood work reports. The facility's policy directed that consulting physician orders be verified and documented in a timely manner, but this procedure was not followed, leading to the deficiency in care for the resident.
What surveyors are citing around you — mapped
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
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Nursing homes near Waterbury
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mattatuck Health Care Facility, Inc. | 2.4 mi | — | 0 | 0 |
| Abbott Terrace Health Center | 2.6 mi | — | 0 | 0 |
| Waterbury Center For Nursing & Rehabilitation Llc | 3 mi | ★★★★★ | 1 | 0 |
| Apple Rehab Watertown | 3.8 mi | ★★★★★ | 14 | 0 |
| Cheshire House Health Care Facility & Rehab Center | 4.2 mi | ★★★★★ | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.