Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Autumn Lake Healthcare At Cromwell during CMS and state inspections, most recent first.
Delayed Pain Assessment and PRN Medication Administration: A resident with chronic pain conditions and PRN tramadol orders reported severe 8/10 hip and leg pain during morning care, but the NA did not notify the assigned LPN, and the LPN was off the unit without transferring med cart keys to another nurse. The resident remained in distress with grimacing and restlessness for about 1 hour and 45 minutes before receiving the ordered analgesic, and later expressed frustration and psychosocial distress about the delay.
Failure to Document and Review Secure-Unit Placement: Three residents were placed on a secure unit without clear documentation of placement criteria, continued placement criteria, or consistent physician, RN, SW, and resident representative involvement. Records showed one resident with severe dementia and two residents with no cognitive impairment on MDS, yet APRN notes, physician orders, and care plan meeting documentation did not establish why they remained on the locked unit or show interdisciplinary review of the least restrictive setting. One resident and the resident’s representative also reported the resident did not want to be on the secure unit and was being denied access to the rehab gym unless escorted.
A resident with an indwelling urinary catheter had the urine collection bag left uncovered and visible from the hallway on multiple observations, despite a physician order for a privacy cover each shift. The ADNS stated a catheter cover should have been provided on admission to protect privacy and dignity, but could not explain why it was not in place; the Foley catheter policy addressed bag changes for discoloration, odor, or leakage but did not mention privacy covers.
A resident with chronic respiratory failure, hypoxia, DM2, and moderate cognitive impairment developed a facility-acquired stage 2 pressure ulcer on the ear from oxygen tubing. Although the care plan and MD order called for foam padding on the tubing and shift checks, observations showed the nasal cannula lying directly on the wound without foam padding, and the resident stated the padding kept falling off.
A resident with CKD, HF, and disc degeneration had intact cognition and was independent with basic ADLs, yet the facility did not obtain podiatry consent after the resident transitioned to LTC and did not provide podiatry services. The resident’s toenails were observed to be thick, overgrown, and jagged, and the resident reported they had not been trimmed since admission despite repeated requests. Staff confirmed the podiatrist visited monthly and that the resident was not documented as having been seen.
Controlled medications were not stored in separately locked, permanently affixed compartments in the med refrigerator. An LPN, the ADNS, and the DON all confirmed that the North Side and South Side controlled substance boxes were locked but not permanently affixed, and the boxes contained unopened lorazepam vials. The DON stated the boxes had been replaced after the keys broke and she assumed they were affixed, while facility policy required Schedule II-V meds to be stored in separately locked, permanently affixed compartments.
An unlocked medical records room in the basement contained 217 banker boxes of resident records with names, DOBs, MRNs, SSNs, and diagnoses. The DON stated she was not familiar with the facility policy and acknowledged records should be kept in a locked, secured location, but the interview did not explain why the room was left unsecured.
A resident with severe cognitive impairment, total dependence for transfers, and hospice services fell from a wheelchair and sustained a nose skin tear and nasal injury. Hospice had recommended a Broda chair due to trunk instability, but staff placed the resident in a transport wheelchair instead. The nurse’s note and incident report did not document hospice notification of the fall, and interviews showed the facility had not communicated the hospice seating recommendation to the staff member who used the wrong chair.
MDS tobacco use coding errors affected 3 residents. Each resident had diagnoses including COPD, and care plans and smoking assessments documented active cigarette use, but their annual MDS assessments were coded as not using tobacco. The MDS Coordinator acknowledged the coding was incorrect, and the DON stated residents who smoke should be coded as smoking on the MDS.
The facility was found to have multiple deficiencies in food storage and sanitation practices. Observations included undated and improperly stored food items, unsanitary conditions in the kitchen and storage areas, and a lack of adherence to facility policies on cleanliness and food safety. The Dietary Manager was unaware of some issues, such as dirt and debris from recent air conditioner installation.
The facility did not submit PBJ data for the third quarter of 2023 as required by CMS. The Administrator was aware of this issue and noted that the corporate office was responsible for the submission but failed to do so.
The facility failed to maintain a safe and clean environment across multiple units, with issues such as exposed plumbing, discolored ceiling tiles, broken window blinds, and missing cover plates. The DOM was unaware of how long these problems persisted, indicating a lack of oversight and prompt action.
The facility failed to report resident-to-resident altercations to appropriate agencies. In one case, a resident with dementia was involved in altercations with another resident, resulting in physical contact. The DNS did not notify Adult Protective Services due to a lack of awareness of reporting requirements. In another incident, a cognitively impaired resident touched another resident inappropriately, but the facility did not report it to the state agency, believing there was no malintent. Additionally, a physical altercation over a cellphone occurred between two residents, but Adult Protective Services were not informed.
The facility failed to provide food at a palatable and safe temperature, as reported by several residents who received cold and unappealing meals. A test tray confirmed that the meatloaf and cheesecake were not within acceptable temperature ranges, with issues attributed to a non-functioning pellet plating system and improper storage of desserts.
A resident with hemiplegia and chronic incontinence did not receive timely incontinent care, as required by their care plan. Observations showed a 4-hour gap in care, with dried fecal material found on the resident. Interviews with staff revealed inconsistencies in care timing, and no specific incontinence care policy was provided.
The facility failed to monitor fluid intake for two residents with kidney failure on fluid restrictions, leading to deficiencies in care. One resident with chronic kidney disease had a fluid restriction of 1200 ml per day, but records did not indicate total intake for each 24-hour period. Another resident with end-stage renal disease had intake records not exceeding 480 ml per day without a 24-hour total documented. Staff interviews revealed a lack of process to monitor fluid goals, contributing to the deficiency.
A LTC facility failed to follow physician orders for two residents, leading to deficiencies in medication administration. One resident did not have blood pressure monitored as required before Atenolol administration, resulting in over 340 missed readings. Another resident received incorrect Vitamin D3 dosage and Procrit was administered despite hemoglobin levels exceeding prescribed limits. The facility's medication administration policies were not adequately followed.
A facility failed to maintain proper infection control during wound care for a resident with a stage 4 pressure ulcer, as an LPN did not wear a gown despite EBP requirements. Additionally, the facility's laundry services were found to be unclean, with debris on equipment and improper storage of clean laundry. The facility's policies lacked detailed procedures for maintaining cleanliness in the laundry area.
The facility did not act on concerns raised by the Food Committee, as residents reported that their feedback was not addressed. Specific requests for meal preferences were documented but not implemented, and the Dietary Department lacked a policy for responding to these concerns.
A resident with a new diagnosis of schizoaffective disorder was not referred for a Level II PASRR evaluation as required. Despite the resident's significant change in mental health status, the facility did not submit the necessary referral to the state-designated authority. The social worker, new to the facility, was unaware of the oversight, which was contrary to the facility's policy on coordinating assessments with the PASRR program.
The facility failed to properly date and discard multi-dose vials and expired medications, as observed in several medication storage rooms. Opened vials of Tuberculin PPD and Lidocaine lacked proper dating, and expired medications like Biotin and Omeprazole were not discarded timely. Staff interviews revealed a lack of awareness of the facility's policy on medication dating and disposal, and the facility could not provide a specific policy for multi-use vials.
Delayed Pain Assessment and PRN Medication Administration
Penalty
Summary
The facility failed to ensure timely assessment and management of pain for one resident who had diagnoses including radiculopathy of the lumbar region, cervicalgia, dorsalgia, myasthenia gravis, chronic back pain, and lumbar degenerative disc disease. The resident’s care plan identified acute and chronic pain and directed staff to assess pain every shift, coordinate with the physician as needed for optimal pain control, and administer analgesics per physician orders. The resident also had a quarterly MDS assessment showing a BIMS score of 13, indicating normal cognitive function, and required PRN pain medication. On 3/30/26, the resident reported severe sharp, stabbing pain in the right hip and right leg during morning care and requested pain medication, stating the pain was unbearable and rating it 8/10. The nurse aide did not notify the assigned LPN of the resident’s pain, stating she thought the nurse already knew. The assigned LPN was off the unit and did not know the resident was in pain, and another LPN on the unit was also unaware because the medication cart keys had not been transferred to her. A handwritten note was later found on the medication cart, after which the assigned LPN returned to the resident’s room to assess the resident and administer the ordered medication. The resident waited approximately 1 hour and 45 minutes after first reporting pain before receiving tramadol 50 mg, which was ordered every 12 hours as needed for chronic pain. Observation during the delay showed facial grimacing, eyes closed, restlessness, and difficulty finding a comfortable position in bed. The resident later stated the pain had decreased but expressed frustration and distress about waiting that long for medication, and the DON stated staff were responsible for communicating pain reports to the nurse and transferring medication cart keys when a nurse left the unit or went on break.
Failure to Document and Review Secure-Unit Placement
Penalty
Summary
The facility failed to ensure a systematic process for determining placement, continued placement, physician involvement, resident representative involvement, interdisciplinary review, or the impact of residing on a secure unit for 3 of 3 sampled residents on the secure unit. The deficiency was identified during review of clinical records, facility policy, and interviews, and involved Residents #30, #34, and #69, all of whom were placed on the secure unit without documentation showing criteria for placement or continued placement on that unit. Resident #30 had diagnoses including Alzheimer’s dementia, anxiety disorder, and epilepsy, and was assessed as severely cognitively impaired, non-ambulatory, and requiring total staff assistance with multiple activities of daily living. The record identified the resident as an elopement risk and included interventions such as room placement on the secure unit, but the physician orders and APRN notes reviewed did not direct placement on the secure unit. Resident #34 had diagnoses including vascular dementia, schizoaffective disorder, and personality disorder, but the annual MDS identified no cognitive impairment, no wandering behaviors, and independence with mobility and self-care. Although the care plan identified the resident as an elopement risk and the record showed exit-seeking behaviors, APRN documentation did not identify criteria for remaining on the secure unit, and the social service care plan meeting note did not show resident representative involvement, discussion of the least restrictive area, or interdisciplinary review of the impact of secure-unit placement. Resident #69 had diagnoses including Wernicke’s encephalopathy, alcohol abuse, and protein calorie malnutrition, and the quarterly MDS identified no cognitive impairment, no wandering behavior, and independence with mobility and self-care. The care plan identified the resident as an elopement risk and placed the room on the secure unit, but APRN notes, physician orders, and nursing notes did not identify criteria to remain on the secure unit. During interview and observation, the resident stated he/she needed escorting off the locked unit to ride the exercise bike in the rehab gym and reported staff said they did not have time to accompany him/her. The resident’s representative stated he/she did not want the resident on the secure unit and wanted discussion of a less restrictive placement, while the DON and SW stated they could not identify routine criteria or reevaluation for secure-unit placement and could not provide information showing resident representative involvement, physician evaluation, or interdisciplinary review of whether the resident was in the least restrictive environment.
Uncovered Urinary Catheter Bag Visible From Hallway
Penalty
Summary
The facility failed to provide a privacy bag for a resident with an indwelling urinary catheter, despite a physician's order dated 3/27/26 directing that a privacy cover be on the urinary collection bag each shift. Resident #180 had diagnoses including a neurological cause of urinary retention, chronic kidney disease, weakness, and a comprehension communication deficit. The nursing admission assessment identified the resident as cognitively intact and needing varying levels of assistance with eating, oral hygiene, toileting, walking, and transferring. The baseline care plan identified the indwelling urinary catheter related to urinary retention and included keeping the catheter bag and tubing below the bladder and away from the room entrance door. Observations on 3/29/26 showed the resident lying in bed with an uncovered urinary catheter bag visible from the hallway, first filled with 700 milliliters of yellow urine and later with 300 milliliters of yellow urine. During an observation and interview, the ADNS saw the uncovered catheter bag visible from the hallway and stated that a catheter cover should have been provided on admission to ensure privacy and dignity, but could not identify why it had not been provided. After surveyor inquiry, a blue privacy bag was placed on the urinary catheter bag. The Foley catheter policy addressed changing the catheter bag as needed for discoloration, odor, or leakage, but did not indicate the use of privacy covers to maintain dignity.
Failure to Maintain Foam Padding on Oxygen Tubing for Pressure Ulcer
Penalty
Summary
A resident with chronic respiratory failure, hypoxia, and DM2, who was dependent on staff for bed mobility and transfers and had moderate cognitive impairment, developed a stage 2 pressure ulcer between the right ear and the head where the ear met the head. The resident’s care plan identified a potential for impaired skin and pressure ulcer injury related to oxygen tubing use, with interventions to administer treatments as ordered and check skin and oxygen tubing placement every shift. A nurse’s note documented the pressure ulcer and that foam padding was placed on the oxygen tubing, and a physician’s order directed foam padding to the bilateral earpieces with placement checks every shift. However, review of the treatment record from 3/18/26 through 3/31/26 did not identify that the resident refused the foam padding or removed it, and observations showed the nasal cannula lying directly on the wound without foam padding. The resident stated the padding kept falling off, and the ADNS confirmed the wound was a facility-acquired stage 2 pressure ulcer caused by oxygen tubing and that the resident should have been wearing foam protectors as an intervention to prevent deterioration of the pressure ulcer.
Failure to Obtain Podiatry Consent and Provide Foot Care
Penalty
Summary
The facility failed to obtain consent and provide podiatry services for one sampled resident with diagnoses including disc degeneration, chronic kidney disease, and heart failure. The quarterly MDS identified the resident as cognitively intact with a BIMS of 13 and independent for eating, dressing, and toileting. The care plan noted a self-care performance deficit related to a deconditioned status, with interventions to adjust to the resident’s physical function and to check nail length with bathing. However, the physician’s orders reviewed did not include an order for podiatry services, despite other ancillary service orders being present. During observation, the resident was found in bed with feet exposed and toenails that were thick, overgrown approximately 1/4 inch, and the right great toenail jagged and uneven. The resident stated the toenails had not been trimmed since admission in October 2025, despite asking staff to do so. Staff interviews confirmed the facility maintained a podiatry list overseen by the scheduler and that the podiatrist visited monthly to provide toenail trimming for residents in need, but the resident’s record did not show any podiatry visit since admission. The DON stated that once the resident transitioned from short-term rehabilitation to LTC, a signed podiatry consent should have been obtained because services were provided by an outside vendor, but no signed consent was present in the record at the time of review.
Controlled Medications Not Stored in Permanently Affixed Refrigerator Compartments
Penalty
Summary
The facility failed to store Schedule II-V controlled medications in a separately locked, permanently affixed compartment within the medication refrigerator. During observation of the second floor medication room with an LPN, the North Side controlled substance box in the refrigerator was locked but not permanently affixed, and it contained 1 unopened bottle of lorazepam 2 mg/ml, 30 ml with an expiration date of 3/2027. The South Side controlled substance box was also locked but not permanently affixed, and it contained 4 unopened bottles of lorazepam 2 mg/ml, 30 ml with the same expiration date. The LPN stated she was unaware the controlled substance storage in the medication refrigerator needed to be permanently affixed and said she would have notified her supervisor if she had known. The ADNS confirmed that both controlled substance boxes were locked but not permanently affixed to the refrigerator and stated they were required to be permanently affixed. The DON stated the keys to both boxes had broken approximately 6 months earlier and were replaced with new boxes, and she assumed the boxes had been permanently affixed when replaced; she also stated it was her responsibility and facility policy to ensure narcotic boxes were permanently affixed. The facility policy for storage of undated medications directed that Schedule II-V controlled medications be stored in separately locked, permanently affixed compartments.
Unsecured Medical Records Room
Penalty
Summary
The facility failed to ensure resident-identifiable information and resident medical records were stored in a secure location. On observation, an unoccupied and unlocked medical record room in the basement contained 217 banker boxes of resident medical records dated from 2013 to 2026, with personally identifiable information including names, dates of birth, medical record numbers, social security numbers, and diagnoses. During interview, the DON stated she was not familiar with the facility policy on resident medical records and personally identifiable information, and acknowledged that medical records should be stored in a secured, locked location and that staff entering the room were responsible for locking it when leaving. Review of the facility policy dated 5/7/24 stated that clinical records would be safeguarded against loss, destruction, or unauthorized use and kept in a locked and monitored area of the Medical Records Department.
Failure to Communicate Hospice Seating Needs and Fall Injury
Penalty
Summary
The facility failed to ensure appropriate hospice provider communication occurred after a resident with severe cognitive impairment, short- and long-term memory problems, fluctuating inattention, total dependence for transfers and bed mobility, and a history of falls was enrolled in hospice care. The resident’s care plan identified a terminal prognosis and included interventions to work cooperatively with the hospice team. Hospice RN documentation showed that a Broda chair was recommended because of the resident’s trunk instability and lack of control, and the hospice vendor reported the chair had been delivered to the facility and placed in the resident’s room several days before the fall. On the day of the incident, the resident was observed on the floor in front of a wheelchair after leaning forward and falling out of the chair. The resident had a small open area on the bridge of the nose and right inner nostril, and the incident report described a small skin tear on the bridge of the nose and an open area inside the right nostril. The nurse’s note and the facility accident and incident report did not document that hospice was notified of the fall with injury. Interviews later identified that the resident had been placed in a black transport wheelchair instead of the Broda chair recommended by hospice. Facility staff statements indicated the assigned NA, who was from a staffing agency, used the transport wheelchair and did not ask which chair should have been used. The hospice RN stated the facility never notified the hospice vendor of the fall and that the resident should have been seated in the Broda chair because a transport chair was not appropriate to stabilize the resident’s trunk. Facility documentation and interviews also showed the hospice recommendation had been placed in the hospice binder, but the recommendation was not reflected in the resident’s care directions used by nursing assistants at the time of the fall.
MDS Tobacco Use Coding Errors
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessments for tobacco use for 3 of 3 residents reviewed for smoking. Resident #63 had diagnoses including chronic obstructive pulmonary disease, paranoid schizophrenia, and type 2 diabetes, and an annual MDS identified severe cognitive impairment with no tobacco use, even though the care plan identified the resident as a supervised smoker and smoking assessments documented cigarette use ranging from 2 to 10 cigarettes a day over multiple assessments. Resident #161 had diagnoses including chronic obstructive pulmonary disease, dementia, and nicotine dependence, and an annual MDS also indicated no tobacco use despite the care plan identifying smoking-related injury risk and smoking assessments documenting cigarette use ranging from 2 to 10 cigarettes a day over multiple assessments. Resident #168 had diagnoses including chronic obstructive pulmonary disease, acute and chronic respiratory failure with hypoxia, and nicotine dependence, and an annual MDS identified no tobacco use even though the care plan identified the resident as at risk for injury due to smoking and smoking assessments documented use of 1 to 2 cigarettes a day over multiple assessments. The MDS Coordinator stated that the comprehensive MDSs for all 3 residents were incorrectly coded as not using tobacco and that, because they were active smokers at the time of assessment, the coding should have included tobacco use. The DON stated that residents who smoke should be correctly coded as smoking on their MDSs, and the RAI manual directed that if a resident used tobacco products within the look-back period, section J1300 should indicate yes for tobacco use.
Deficiencies in Food Storage and Sanitation Practices
Penalty
Summary
The facility failed to maintain proper food storage and sanitation standards in the Dietary Department, as observed during a tour with the Dietary Manager. Several deficiencies were noted, including an accumulation of dust and debris on the threshold of the walk-in refrigerator, and multiple open food items such as hotdogs, Ricotta cheese, pancakes, omelets, French toast, and pork crumble that were not dated with open or expiration dates. Additionally, the Ricotta cheese was found with a black and orange-like substance, and the container for Spanish onions was visibly dirty and uncovered. The ice machine had a heavy accumulation of white and dark substances inside, and dust on the side vents, indicating a lack of regular cleaning. In the Dry Storage room, a bag of dried cranberries was found open to air, and heavy dirt and debris were observed behind the can shelving near the air conditioner. The Dietary Manager was unaware of the dirt and debris, attributing it to recent air conditioner installation. Furthermore, a stained ceiling tile was noted in the third-floor Nourishment Room. The facility's policies on maintaining clean and sanitary food preparation and storage areas were not adhered to, as evidenced by the unsanitary conditions and improper food storage practices observed during the survey.
Failure to Submit PBJ Data for Third Quarter 2023
Penalty
Summary
The facility failed to submit Payroll Based Journal (PBJ) data for the third quarter of 2023, which includes the months of April, May, and June, as required by the Centers for Medicare and Medicaid Services (CMS). During an interview and review of facility documentation on July 25, 2024, the Administrator acknowledged awareness of the failure to submit the PBJ data. The Administrator indicated that the responsibility for submitting the PBJ data to CMS lay with the facility's corporate office, which did not fulfill this obligation.
Environmental Deficiencies Across Multiple Units
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for residents across multiple units, as observed during surveys conducted on two separate days. On the Elm Unit, several issues were identified, including exposed plumbing and wall studs due to missing drywall and tile, discolored ceiling tiles with a black substance, and peeling paint with holes in the drywall. The Director of Maintenance (DOM) was unable to specify how long these issues had persisted, indicating a lack of awareness and oversight. On the Maple Unit, similar deficiencies were noted, such as a fallen radiator faceplate, broken window blinds, a permanently locked bathroom door handle, and discolored ceiling tiles. The DOM again expressed uncertainty regarding the duration of these problems, suggesting that they were not promptly identified or addressed during environmental rounds. Additionally, the Oak Unit exhibited issues like stained toilet bowls, exposed sheetrock, missing cover plates with exposed wires, and dusty bathroom vents. The DOM acknowledged that some of these issues were missed during previous inspections. The Hickory Unit also had notable deficiencies, including holes stuffed with paper towels and a missing faceplate cover above a resident's bed. The DOM confirmed that environmental rounds are conducted quarterly, and maintenance logs are reviewed routinely. However, the persistence of these issues across multiple units indicates a systemic failure to ensure a safe and sanitary environment for residents, as the DOM admitted that the identified concerns were unacceptable.
Failure to Report Resident-to-Resident Altercations
Penalty
Summary
The facility failed to report allegations of mistreatment involving resident-to-resident altercations to the appropriate agencies, including Adult Protective Services and the state survey agency. In one instance, a resident with dementia and hallucinations, identified as Resident #20, was involved in two separate altercations with another resident, Resident #153, who also had dementia and hallucinations. During these incidents, Resident #20 slapped Resident #153, and in another instance, hit Resident #153 in the face. Although the police and responsible parties were notified, Adult Protective Services were not informed, as the Director of Nursing Services (DNS) was unaware of the requirement to report such incidents. In another case, Resident #140, who was severely cognitively impaired, was observed touching another resident, Resident #80, on the chest over clothing. Despite the incident being reported to the DNS and an internal investigation being conducted, the facility did not report the incident to the state survey agency. The DNS and other staff believed that due to the cognitive impairments of both residents, there was no malintent, and thus, the incident was not reportable. Additionally, an altercation occurred between Resident #20 and Resident #668, where Resident #668 attempted to take Resident #20's cellphone, leading to a physical confrontation. Both residents sustained minor injuries, and while the police and responsible parties were notified, Adult Protective Services were not informed. The DNS admitted to being unaware of the state guidelines requiring notification of Adult Protective Services in such cases.
Food Temperature and Palatability Deficiency
Penalty
Summary
The facility failed to ensure that food served to residents was palatable, attractive, and at a safe and appetizing temperature. Multiple residents reported dissatisfaction with the food, citing issues such as receiving cold meals, unappealing presentation, and a lack of awareness about meal options. Specific complaints included cold food, mushy vegetables, and a general lack of appeal in the meals provided. These observations were corroborated by interviews with several residents who expressed their dissatisfaction with the quality and temperature of the food served. A test tray conducted with the Dietary Manager revealed that the food temperatures were not within the acceptable range. The meatloaf's internal temperature was significantly below the palatable temperature of 135 degrees Fahrenheit, and the cheesecake was served at a temperature much higher than the recommended 38 to 40 degrees Fahrenheit. The Dietary Manager identified that the cheesecake was stored on an open metal cart for an extended period, contributing to its high temperature, while the low temperature of the meatloaf was attributed to a non-functioning pellet plating system.
Failure to Provide Timely Incontinent Care
Penalty
Summary
The facility failed to provide timely incontinent care to Resident #103, who was diagnosed with hemiplegia and hemiparesis following a stroke and was always incontinent of bowel and bladder. The resident was totally dependent on staff for bed mobility and toileting hygiene. The care plan required that the resident receive incontinent care every 2 hours and as needed. However, observations on 7/24/24 revealed that the resident had not received care for approximately 4 hours, as dried fecal material was found on the resident's buttocks, indicating a lack of timely care. Interviews with nursing assistants and the LPN revealed inconsistencies in the timing of care provided to the resident. NA #2 claimed to have provided care at 7:45 AM and checked the resident at 11:00 AM, but the surveyor did not observe NA #2 entering the room at that time. The LPN expected care to be provided every 2 hours, but the resident was not checked until 11:39 AM. The Director of Nursing Services stated that care is given 4 times a shift and as needed, but no specific policy for incontinence care was provided upon request.
Failure to Monitor Fluid Intake for Residents on Fluid Restrictions
Penalty
Summary
The facility failed to implement a systematic approach to assess daily fluid intake for residents with kidney failure on fluid restrictions, leading to deficiencies in care for two residents. Resident #94, diagnosed with chronic kidney disease Stage 4 and diabetes, had a physician's order for a fluid restriction of 1200 ml per day. However, the Medication Administration Record (MAR) did not indicate a total fluid intake for each 24-hour period, and the clinical record lacked calculations of total fluid intake from 7/14/24 through 7/20/24. Interviews revealed that the facility did not have a mechanism to total fluid intake every 24 hours, and there was no designated staff to monitor if the fluid goal was met or exceeded. Resident #152, with diagnoses including end-stage renal disease and congestive heart failure, was also on a fluid restriction of 1200 ml per day. Observations noted dry mucous membranes, and intake and output records showed documentation that did not exceed 480 ml per day without a 24-hour total documented. The Director of Nursing Services (DNS) acknowledged that the intake and output record flowsheets were not part of the official clinical record and that a total intake for 24 hours was not documented. Interviews with staff indicated a lack of process to identify when a resident did not meet their fluid goal for consecutive days. The facility's policy directed staff to record fluid intake and total amounts at the end of each shift, but this was not consistently followed. The clinical record for Resident #152 failed to reflect documentation of total fluid intake meeting the fluid restriction, with 14 days of documented amounts not totaling over 800 ml for 24 hours. There was no corresponding nursing staff documentation or assessments to indicate the resident's hydration status when fluid intake did not meet 800 ml. The facility lacked a process to tally 24-hour totals and identify deviations from fluid goals or restrictions, contributing to the deficiency.
Medication Administration Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to physician orders for two residents, leading to deficiencies in medication administration. For Resident #25, who had diagnoses including hypertension and atrial fibrillation, the physician ordered Atenolol to be administered with specific parameters: holding the medication if the systolic blood pressure was less than 100 or the heart rate was less than 60 beats per minute. However, the facility did not consistently take the resident's blood pressure before administering the medication, resulting in over 340 missed blood pressure readings. Interviews with LPNs revealed that the electronic system did not prompt for a blood pressure reading, contributing to the oversight. For Resident #107, who had conditions such as anemia and chronic myeloid leukemia, there were multiple issues with medication orders. A pharmacy consultant recommended a change in Vitamin D dosage, which was misinterpreted by the APRN, leading to the resident receiving Vitamin D3 50,000 units twice a month instead of once. Additionally, the resident was to receive Procrit with specific parameters to hold the medication if hemoglobin levels were above 10. Despite this, Procrit was administered when the hemoglobin was 11.1 and 10.1 on separate occasions, contrary to the physician's orders. The APRN and LPNs involved were unaware of the errors in medication administration. The facility's policies on administering medications and following physician orders were not adequately followed, as evidenced by the lack of pre-administration assessments and incorrect medication orders. The absence of a facility policy for physician orders further compounded the issue, leading to the administration of unnecessary medications and failure to adhere to prescribed parameters.
Infection Control and Laundry Cleanliness Deficiencies
Penalty
Summary
The facility failed to maintain proper infection control techniques for Enhanced Barrier Precautions (EBP) during wound care for a resident with subacute osteomyelitis and a stage 4 pressure ulcer. The resident was cognitively intact and dependent on staff for various activities. Despite the presence of EBP signage and a physician's order requiring EBP, an LPN performed wound care without wearing a gown, as required. The LPN was unaware of the EBP requirement for the resident and only realized the oversight after reviewing the Medication Administration Record and Treatment Administration Record. The Infection Preventionist confirmed that the nurse should have worn a gown and gloves during wound care, and noted that the facility was still working on staff education regarding EBP. In the facility's laundry services, the environment was not maintained in a clean state, as observed in the laundry room. There was a moderate buildup of debris on washers, dryers, and other surfaces, and a dark gray substance on the ceiling fan and filters. The Regional Environmental Services Manager, who visits the facility weekly, acknowledged the need for thorough cleaning, as similar conditions had been observed previously. The Environmental Services Director also noted issues with open windows allowing substances to re-enter the dryer room, where clean laundry was stored uncovered. Despite the cleaning schedule being signed off as completed, the observed conditions indicated otherwise. The facility's laundry policy did not include specific procedures for clean laundry operations, such as drying, folding, storage, or cleaning of the laundry areas. This lack of detailed policy contributed to the deficiencies observed in maintaining a clean environment for laundry processing. The facility's failure to ensure proper infection control and environmental cleanliness in the laundry area highlights significant lapses in adherence to established protocols and procedures.
Failure to Address Food Committee Concerns
Penalty
Summary
The facility failed to address concerns raised by the Food Committee, as evidenced by interviews with residents and staff, and a review of committee minutes. During a Resident Council meeting, two residents reported that despite providing feedback during monthly Food Committee meetings, no corrective actions were taken. Specific requests from residents, such as smaller portions, no bread, dislike of pork, and preferences for egg servings, were documented in the committee minutes but were not acted upon by the Dietary Department. The Regional Dietary Manager's review of food tickets from January to July 2024 confirmed that no notes were added to reflect these requests. Additionally, the Dietary Manager acknowledged the absence of a policy for responding to Food Committee concerns.
Failure to Refer Resident for Level II PASRR Evaluation
Penalty
Summary
The facility failed to refer a resident for a Level II Preadmission Screening and Resident Review (PASRR) evaluation and determination after a new psychiatric diagnosis was identified. The resident, who was initially screened with a PASRR Level I on March 4, 2020, was diagnosed with schizoaffective disorder in September 2020. Despite this significant change in the resident's mental health status, the facility did not submit a referral for a Level II PASRR evaluation to the appropriate state-designated authority. The resident's medical history included dementia, congestive heart failure, and a new diagnosis of schizoaffective disorder. Psychological service notes from September 2020 and May 2022 confirmed the presence of a psychotic disorder and schizoaffective disorder, respectively. The resident's care plan, updated in January 2024, acknowledged the psychosocial wellbeing problem related to the schizoaffective disorder. However, the social worker, who began working at the facility in 2023, was unaware of why the Level II PASRR had not been completed and admitted that it might have been overlooked. The facility's policy mandates coordination with the PASRR program to ensure appropriate care for residents with mental diseases, but this was not adhered to in this case.
Medication Storage Deficiencies
Penalty
Summary
The facility failed to adhere to its medication storage policies, resulting in several deficiencies related to the handling of multi-dose vials and expired medications. During a review of the medication storage rooms, it was observed that a vial of Tuberculin PPD on the Maple Unit was opened and dated 2/28/24, well beyond the 30-day usage period. Additionally, a vial of Lidocaine on the same unit was opened but lacked an opening date. On the Oak Unit, a bottle of Biotin with an expiration date of 1/2024 was found, and two bottles of Omeprazole suspension were noted to be expired, with one opened and dated 5/20/24 and the other sealed but expired on 7/18/24. Similarly, on the Elm Unit, a vial of Tuberculin PPD was opened and dated 3/13/24, exceeding the recommended usage period. Interviews with facility staff revealed a lack of awareness and adherence to the facility's policy regarding the dating and disposal of multi-dose vials. The ADNS and Infection Control Nurse confirmed that the policy required dating upon opening and discarding after 30 days, but an LPN was unaware of this policy. Pharmacists highlighted the importance of adhering to expiration dates to prevent infection risks. Despite requests, the facility could not provide a specific policy for multi-use medication vials, indicating a gap in documentation and staff training.
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Nursing homes near Cromwell
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pilgrim Manor | 0.6 mi | ★★★★★ | 0 | 0 |
| Portland Care & Rehab Centre, Inc | 1.6 mi | ★★★★★ | 19 | 0 |
| Water's Edge Center For Health & Rehabilitation | 3.1 mi | ★★★★★ | 15 | 0 |
| Apple Rehab Cromwell | 3.4 mi | ★★★★★ | 20 | 0 |
| Wadsworth Glen Health Care And Rehabilitation Cent | 3.6 mi | ★★★★★ | 0 | 0 |
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