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 New Britain during CMS and state inspections, most recent first.
Unsafe water temperatures were found in multiple resident rooms, with readings above the facility's acceptable range and staff failing to report the elevated temperatures. In a separate event, an NA applied a petroleum-containing product to a resident receiving continuous O2 via nasal cannula without an order and without recognizing the safety issue. Surveyors also found a prescribed floor mat for a resident with dementia and a fall history was not consistently in place, and at one point an over-the-bed table was placed on top of the mat.
Failure to Report Bruise of Unknown Origin: A resident with dementia and total dependence for transfers was found with a bruise above the eyebrow during morning care. Staff documentation was conflicting, no RMS or reportable event entry was completed, and the event was not reported to the state agency even though the cause of the bruise was not supported by the incident statements or other documentation.
Incomplete Investigation of Bruise of Unknown Origin: A resident with severe cognitive impairment and total dependence for transfers was found with a bruise above the eyebrow during morning care. Staff documentation did not support the explanation that the resident bumped a hoyer lift bar, no RMS or state report was completed, and the investigation did not include all required staff interviews from the lookback period.
Failure to update the care plan for anxious transfer behavior. A resident with dementia, cerebral infraction, and anxiety was totally dependent on staff for transfers and other care. After the resident bumped the forehead on a mechanical lift bar during transfer and developed discoloration above the brow, an RN stated the resident became anxious during transfers and often grabbed the lift bar, but the behavior had not been care planned.
Failure to ambulate a resident according to orders and the care plan. A cognitively intact resident with CHF, respiratory failure, and spinal stenosis was ordered to receive assistance with ambulation using a RW and had ADL deficits documented in the care plan. After therapy ended due to insurance, the resident reported staff were not walking him/her after a room change and were using a wheelchair even for bathroom trips. NA flowsheets showed little or no ambulation documentation across multiple shifts, and therapy and nursing leadership could not confirm consistent implementation of the ambulation program.
Infection Control Lapses During Blood Glucose Monitoring: An LPN failed to follow infection control practices while checking a resident’s blood glucose. The meter was placed on the resident’s blanket and later on a roommate’s over-bed table without a barrier, a multi-vial strip bottle was brought into the room, gloves were not removed or hands sanitized between attempts, and the meter was placed on the med cart before disinfection. Interviews and facility policy confirmed the meter should have been placed on a clean surface and disinfected after use.
A resident with severe cognitive impairment and multiple diagnoses experienced a significant weight loss, which was not communicated to the physician or family as required by the facility's policy. Despite orders for monthly weight checks, no weights were recorded for several months, and the resident lost 13% of their weight over six months. Interviews revealed a lack of communication and documentation, with staff unaware of the weight loss and failing to notify the necessary parties.
The facility failed to include necessary interventions and monitoring for two residents on anticoagulant medication in their care plans. One resident with severe cognitive impairment and non-ambulatory status was on Apixaban, but the care plan lacked interventions for bleeding risks. Another resident with moderately impaired cognition and ambulatory status also had an incomplete care plan for anticoagulant therapy. Interviews revealed that both MDS and nursing staff were responsible for ensuring comprehensive and updated care plans, as per the facility's policy.
A resident with multiple health conditions experienced significant weight loss due to the facility's failure to monitor and record monthly weights as per physician's orders. Despite the care plan's directive for regular weight checks, the resident was not weighed for several months, leading to a weight loss of over 10 percent. The lapse was attributed to a vacancy in the unit manager position and inadequate follow-up on missing weight reports by the dietician.
A resident with chronic conditions was observed self-administering medications without a proper assessment or physician's order. Despite the facility's policy against leaving medications at the bedside, an LPN left medications with the resident, citing their preference for privacy. The DNS confirmed the lack of assessment and suggested a re-evaluation for self-administration.
A facility failed to ensure congruence between a physician's order and a resident's signed Advance Directives. The resident, with conditions like pulmonary fibrosis and asthma, had a Full Code order, while their Advance Directive indicated a DNR status. An LPN identified the discrepancy, and the DNS noted that delays in obtaining signatures could lead to a default Full Code status. The resident confirmed their preference for a DNR status.
The facility failed to ensure a physician's order for splints for a resident with quadriplegia, leading to inconsistent application. Additionally, another resident received expired Lansoprazole for ten days due to lapses in checking expiration dates. Staff interviews confirmed the absence of necessary orders and adherence to protocols, highlighting deficiencies in following established procedures.
A facility failed to administer Lansoprazole oral suspension as ordered for a resident with GERD and other conditions. The medication was expired, yet it was signed off as administered multiple times. An LPN admitted to not administering the medication, and the DNS was aware of the issue. Facility policy requires adherence to medication orders, including checking expiration dates.
A facility failed to appropriately store medications, as several expired medications were found in a medication room. An LPN confirmed that it was the staff's responsibility to check for expired medications. Despite this, an expired Lansoprazole suspension was administered to a resident multiple times. The facility's policy requires expired drugs to be returned or destroyed, which was not followed.
The facility failed to identify and maintain records of residents with known MDRO colonization and did not appropriately cohort them. A resident with MRSA and C-diff and another with ESBL E.coli were sharing a room, contrary to facility policy. The MDRO log was not updated to reflect their histories, and the DNS and an LPN acknowledged the oversight, noting that the log should be updated daily after reviewing records and reports.
The facility failed to complete and submit quarterly MDS assessments for three residents within the required timeframes. An LPN responsible for these assessments acknowledged the delays, citing staffing shortages as a contributing factor. The assessments were completed between 40 to 58 days late, contrary to the guidelines that require completion within 14 days of the assessment reference date.
The facility failed to complete annual performance evaluations for two nurse aides due to recent turnover and lack of a specific policy requiring such evaluations. Interviews revealed that only annual competencies were being completed, not performance evaluations, as typically done by the unit manager.
A resident with hypothyroidism did not receive Levothyroxine for 27 days due to a transcription error by an RN distracted by a personal call. The facility's protocol for second and third checks failed to catch the omission, leading to elevated TSH levels upon discharge.
The facility failed to implement a physician's order to obtain laboratory blood work for a newly admitted resident with multiple diagnoses. Despite a physician's order to draw a CBC and CMP, the tests were not performed, and there was no documentation explaining the omission.
Unsafe Water Temperatures, Oxygen-Related Petroleum Exposure, and Inconsistent Fall Intervention
Penalty
Summary
The facility failed to maintain safe hot water temperatures in resident care areas. Surveyors observed hot water temperatures above 120 F in 44 of 64 resident rooms on the second and third floors, with temperatures ranging from 126.3 F to 141.4 F. When the Facilities Director tested rooms with the surveyor, all 16 rooms tested exceeded 120 F, with temperatures ranging from 120.8 F to 145.4 F. Facility logs also showed multiple documented readings above the acceptable range in rooms on the affected floors. The Maintenance Technician stated he checked water temperatures daily in random rooms but did not notify the Facilities Director when readings were above 120 F because he thought they were okay. The Facilities Director, Administrator, and DON stated they were not aware of the high readings and that no action had been taken based on those readings. The facility also failed to maintain a safe environment for a resident receiving continuous oxygen therapy when staff applied a petroleum-based product to the resident's nose, inner nares, and cheeks without a physician's order and without recognizing the safety risk. Resident #11 had COPD, chronic respiratory failure with hypoxia, sleep apnea, moderate cognitive impairment, and was dependent on staff for several activities of daily living. During observation, the resident was receiving oxygen at 2 liters per minute via nasal cannula and had a shiny, wet substance on the nose, nares, and cheeks. An NA stated she had applied a combination of house-stock lotions, including a petroleum-containing ointment, because the resident had dry skin. She stated she was not aware that petroleum-based products should not be used with oxygen therapy. The LPN and DON stated they were not aware the product had been applied and acknowledged the safety concern. The facility further failed to consistently implement a prescribed floor mat intervention for a resident with a history of falls. Resident #13 had unspecified dementia, epilepsy, cataracts, severe cognitive impairment, and was totally dependent on staff for transfers and positioning. The care plan and nurse aide care card directed staff to place a floor mat next to the bed when the resident was in bed and remove it when out of bed. Surveyors observed the resident in bed without the floor mat in place, with the mat stored against the wall. On another observation, the mat was on the floor but an over-the-bed table was placed on top of it. An NA stated the mat was intended to protect the resident if he or she rolled out of bed, and the RN confirmed the table should not have been placed on the mat because it defeated the purpose of the intervention.
Failure to Report Bruise of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin for Resident #16, who had diagnoses including dementia, cerebral infarction, and anxiety and was documented as having severely impaired cognition and total dependence on staff for transfers, bed mobility, and personal hygiene. The resident’s care plan identified a potential for impaired skin integrity related to inactivity and directed staff to use caution during transfers and bed mobility. The resident was also ordered to be transferred by hoyer lift. On 1/22/26, staff identified a 1.5 cm x 0.5 cm bruise above the resident’s left eyebrow during morning care. Documentation included a change in condition note and a nurse’s note stating the resident lightly bumped the forehead on the mechanical lift bar during transfer, but the accident/incident statements did not identify that the resident bumped the head on the lift bar, and the nurse who found the bruise stated she discovered the discoloration when entering the room to provide care and reported it immediately to the nurse. Facility documentation did not show a completed reportable event form or RMS entry for the bruise, and the state agency online reportable events portal did not reflect that the bruise had been reported. Interviews showed conflicting and incomplete documentation about the cause of the bruise. The unit manager stated that if a bruise is found, staff are responsible for starting the RMS, initiating a change in condition form, and obtaining statements, but no RMS had been completed for this event. The ADNS stated that accident/incident reports are completed for suspected injuries and reviewed for reporting, but no documentation or statements were available in her records and the event had not been logged. Later, the unit manager stated she had found misfiled interview statements but acknowledged there were no statements showing the resident actually hit the lift bar or side rail, and the DNS could not identify who reported that the resident bumped the lift bar or locate additional documentation supporting that explanation.
Incomplete Investigation of Bruise of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate a bruise of unknown origin on a resident’s left eyebrow. The resident had diagnoses including dementia, cerebral infarction, and anxiety, and the quarterly MDS identified severely impaired cognition with total dependence on staff for transfers, bed mobility, and personal hygiene. The care plan identified a risk for impaired skin integrity related to inactivity, and the resident was ordered to be transferred by hoyer lift. At 7:30 AM, staff noted a 1.5 cm x 0.5 cm reddish/purplish discoloration above the resident’s left eyebrow. The DNS documented that the resident lightly bumped his/her forehead on the mechanical lift bar during a transfer, but the incident statements did not identify that event, did not establish when the bump occurred, and later interviews could not confirm who reported it. The aide who found the bruise stated only that the discoloration was observed when morning care began and was reported to the nurse. The investigation was incomplete. Facility documentation did not show a completed RMS or reportable event entry for the bruise, and the state agency portal did not reflect that the injury had been reported. The investigative statements did not include the LPN or all nurse aides working the prior 72-hour lookback period as required by facility policy. Interviews showed the unit manager, ADNS, and DNS each lacked complete documentation or could not verify the cause of the bruise, and the resident’s discoloration was not documented as an injury of unknown origin despite no supporting statements confirming the lift-bar explanation.
Failure to Update Care Plan for Anxious Transfer Behavior
Penalty
Summary
The facility failed to update and revise Resident #16’s care plan to address anxious behavior related to transfers and care. Resident #16 had diagnoses including dementia, cerebral infraction, and anxiety, and the quarterly MDS identified severe cognitive impairment with total dependence on staff for transfers, bed mobility, and personal hygiene. The resident’s care plan dated 12/4/25 addressed potential skin integrity impairment related to inactivity and included caution during transfers and bed mobility to prevent striking arms, legs, and hands against hard or sharp surfaces. A nurse progress note dated 1/22/26 documented that Resident #16 sustained a reddish/purplish discoloration above the left brow after bumping the forehead lightly against the mechanical lift bar during transfer; the skin remained intact and neurological checks were within baseline. During interview, RN #1 stated the resident became anxious during transfers, often grabbed the lift bar, and could also pull up on the side rail during care, which could lead to bumping and discoloration, but she had not care planned for the anxious behavior even though she was responsible for updating care plans. The facility policy stated the interdisciplinary team was responsible for periodic review and updating of care plans when there was a significant change in condition, when the desired outcome was not met, and at least quarterly.
Failure to Ambulate Resident According to Orders and Care Plan
Penalty
Summary
The facility failed to ensure Resident #117 was ambulated according to physician's orders and the resident care plan. Resident #117 was admitted with diagnoses including congestive heart failure, respiratory failure, and spinal stenosis. The resident care plan identified ADL deficits and directed assistance of 1 staff member for ambulation to and from the bathroom with a rolling walker, transfers with a rolling walker, bed mobility, and toileting, with therapy as indicated. The admission MDS identified the resident as cognitively intact and requiring maximum assistance of 1 staff member for ambulation. Physical therapy notes showed Resident #117 was discharged from therapy on 4/10/26 due to insurance, and the therapist stated the resident was able to walk with staff at discharge. The resident later reported that after moving from the short-term unit to the long-term care unit, staff had not been walking him/her and were using a wheelchair even to take him/her to the bathroom. The resident also stated therapy had told him/her staff would walk daily after the room change, but this was not happening. Nurse aide flowsheets from 4/17/26 through 4/23/26 lacked documentation that the resident was walked on several shifts, with only limited entries showing ambulation in the room or hallway on some shifts and N/A documented for the rest. The Director of Therapy stated the resident was placed on the ambulation program and that nursing supervision was verbally informed that the resident could be added to the ambulation list and a physician's order obtained for daily walking with assistance and a rolling walker. The Assistant Director of Nursing Services stated the updated ambulation list could not be located, the unit manager had been off, and the new process of placing ambulation status on the care card had not been supported by documented education for nurse aides.
Infection Control Lapses During Blood Glucose Monitoring
Penalty
Summary
The facility failed to maintain appropriate infection control practices during blood glucose monitoring for Resident #85, who was admitted with diagnoses including type 2 diabetes, dementia, and depressive disorder and had severely impaired cognition with dependence for personal hygiene, dressing, and toileting. Physician orders directed blood glucose monitoring twice daily and daily diabetes medications, and the resident’s care plan included diabetes-related interventions. During observation, an LPN entered the room wearing gloves and carried a blood glucose meter, a multi-vial test strip bottle, lancet, alcohol wipes, gauze, and gloves. The meter was placed directly on the resident’s blanket without a barrier, and after an initial failed attempt, the LPN handled another test strip without removing gloves or sanitizing hands before trying again. The LPN then exited the room, discarded used items, and placed the blood glucose meter on the medication cart without disinfecting it before removing gloves and performing hand hygiene. She later re-entered the room, placed the meter on the roommate’s over-bed table without a barrier, and completed the blood glucose check. Interviews confirmed the over-bed table belonged to the roommate, that the meter should not have been placed on the blanket or the roommate’s table, that only one test strip should have been brought into the room, and that the meter should have been disinfected after the initial attempt and after exiting the room. Facility policy stated blood glucose meters are to be cleaned and disinfected after each use according to manufacturer instructions, with gloves removed and hand hygiene performed prior to exiting the room.
Failure to Notify Physician and Family of Significant Weight Loss
Penalty
Summary
The facility failed to notify the physician and resident representative of a significant weight loss for a resident with severe cognitive impairment and multiple diagnoses, including type 2 diabetes mellitus, hypertension, anxiety, vascular dementia, and paranoid schizophrenia. The resident's care plan included monitoring for significant weight loss, but there were no recorded weights from August 2023 through December 2023, despite physician orders for monthly weight checks. The resident experienced a 13 percent weight loss over six months, which was not communicated to the physician or resident representative as required. Interviews with facility staff revealed a lack of communication and documentation regarding the resident's weight loss. The wound nurse, covering as unit manager, was unable to locate monthly weights and could not confirm whether the physician and resident representative were notified. The dietician identified the significant weight loss during a nutritional evaluation and attempted to address it by adding extra food items to the resident's meal tray but did not notify the physician or resident representative, citing it as nursing's responsibility. The facility's Weight Assessment and Intervention policy required nursing to notify the dietician, physician, and family of significant weight loss. However, the Director of Nursing Services (DNS) and the Advanced Practice Registered Nurse (APRN) were not aware of the resident's weight loss, indicating a breakdown in the facility's communication and documentation processes. The deficiency highlights the facility's failure to adhere to its policy and ensure timely notification of significant weight changes to the appropriate parties.
Deficiency in Anticoagulant Care Planning
Penalty
Summary
The facility failed to ensure that the care plans for two residents receiving anticoagulant medication included interventions to address possible side effects and necessary monitoring. Resident #81, who had severe cognitive impairment and was non-ambulatory, was on Apixaban, a high-risk anticoagulant medication, since February 2021. The care plan for Resident #81 did not include interventions related to the use of Apixaban and the increased risk of bleeding associated with anticoagulant therapy. Interviews with the MDS Coordinators revealed that the corporate office directed them to develop anticoagulant care plans only for residents taking Coumadin and Lovenox, and it was identified that both the MDS Coordinator and nursing staff were responsible for ensuring comprehensive and updated care plans. Resident #160, who had moderately impaired cognition and was ambulatory, was also on Apixaban for chronic embolism and thrombosis. The care plan for Resident #160 included monitoring for skin integrity related to subcutaneous anticoagulant use but failed to identify signs and symptoms to monitor for due to anticoagulant therapy. Interviews with the MDS Coordinator and the DNS confirmed that Resident #160 should have had a care plan focused on anticoagulant therapy, and it was the responsibility of both MDS and nursing to update and revise care plans as needed. The facility's Comprehensive Person-Centered Care Plan policy requires the development of individualized comprehensive care plans that include measurable objectives and timetables to meet residents' medical, nursing, mental, and psychological needs. The policy also mandates that care plans incorporate risk factors associated with identified problems and recognized standards of practice. The care planning/interdisciplinary team is responsible for periodic review and updating of the care plans, which was not adequately done for the residents on anticoagulant therapy.
Failure to Monitor Resident's Weight Leads to Significant Weight Loss
Penalty
Summary
The facility failed to ensure timely assessment and monitoring of a resident's weight, leading to a significant weight loss that went unaddressed for several months. Resident #87, who had diagnoses including type 2 diabetes mellitus, hypertension, anxiety, vascular dementia, and paranoid schizophrenia, was not weighed from August 2023 through December 2023, despite a physician's order for monthly weight checks. The resident's care plan highlighted the need for regular weight monitoring due to potential nutritional risks, but this was not adhered to. The deficiency was further compounded by the lack of communication and follow-up among the facility's staff. Interviews revealed that the dietician was responsible for assessing weight loss, while the charge nurse was tasked with recording weights in the electronic medical record. However, due to a vacancy in the unit manager position, there was a lapse in ensuring that weights were recorded, and the dietician's reports on missing weights were not acted upon. This resulted in Resident #87 experiencing a significant weight loss of over 10 percent, which was only identified during a nutritional evaluation in January 2024. The facility's policy required the multidisciplinary team to prevent and intervene in cases of undesirable weight loss, but this was not effectively implemented. The dietician noted that additional food items were provided to the resident after the weight loss was identified, but the initial failure to record and monitor the resident's weight contributed to the deficiency. The DNS confirmed the oversight and acknowledged that missing weights were not reflected in the weight loss report, which hindered timely intervention.
Failure to Assess Resident for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that a resident was properly assessed for self-administration of medications. The resident, who had diagnoses including chronic obstructive pulmonary disease, heart failure, and chronic pain, was observed self-administering medications without a documented assessment or physician's order permitting self-administration. Despite the resident's cognitive intactness, the care plan indicated a self-care deficit, and the resident expressed no desire to self-administer medications in previous assessments. However, during an observation, the resident was found with a medicine cup containing numerous pills, which they proceeded to self-administer. The facility's policy requires that medications should not be left at the bedside and that nurses must remain with the resident until medications are consumed. An LPN admitted to leaving the medications with the resident, citing the resident's preference for privacy. The Director of Nursing Services (DNS) confirmed that the resident should be within the nurse's view during medication administration and acknowledged that the resident was not assessed for self-administration. The DNS suggested that it might be time to re-evaluate the resident for self-administration, as assessments are typically completed upon admission, readmission, and quarterly.
Inconsistency in Code Status Documentation
Penalty
Summary
The facility failed to ensure that the physician's order and the resident's signed Advance Directives were congruent for Resident #126. The resident, who had diagnoses including pulmonary fibrosis, asthma, and chronic cough, had a physician's order indicating a Full Code status, while the signed Advance Directive form indicated a Do Not Resuscitate (DNR) status. This discrepancy was identified during a review of the clinical record, facility documentation, and interviews. The resident had intact cognition and was independent with most activities of daily living, requiring only supervision and setup assistance. An LPN noted the inconsistency between the physician's order and the advanced directives during a check of the electronic medical record and the physical clinical record. The Director of Nursing Services (DNS) acknowledged that advanced directives are reviewed with the resident, family, or conservator within twenty-four hours of admission or readmission, but delays in obtaining signatures can occur, resulting in a default Full Code status. The resident confirmed their wish to maintain the DNR status as per the signed advanced directives. The facility's policy requires that the plan of care be consistent with the resident's documented treatment preferences and/or advanced directives.
Deficiencies in Physician Orders and Medication Administration
Penalty
Summary
The facility failed to ensure a physician's order was in place for the use of splints for Resident #42, who was readmitted with quadriplegia and other conditions requiring maximal assistance. The care plan indicated the need for bilateral hand splints, but a review of the physician's orders from January to May 2024 showed no such order. Observations revealed inconsistent application of the splints, and interviews with staff confirmed the absence of a physician's order, despite the resident's previous order for splints before readmission. The facility's policy required a physician's order for assistive devices, which was not adhered to in this case. For Resident #213, the facility failed to prevent the administration of expired medication. The resident, diagnosed with protein calorie malnutrition and other conditions, had an order for Lansoprazole oral suspension. Observations and interviews revealed that the medication was administered for ten days past its expiration date. The medication was compounded with sterile water and Sodium Bicarbonate, and the pharmacist confirmed it should have been discarded after the expiration date. The facility's policy required checking expiration dates before administration, which was not followed. The deficiencies highlight lapses in following established protocols for physician orders and medication administration. Staff interviews revealed a lack of awareness and adherence to these protocols, resulting in the use of expired medication and the absence of necessary physician orders for assistive devices. The facility's policies on assistive devices and medication administration were not effectively implemented, leading to these deficiencies.
Failure to Administer Medication as Ordered
Penalty
Summary
The facility failed to administer a compounded medication, Lansoprazole oral suspension, as ordered for a resident with diagnoses including protein calorie malnutrition, GERD, and end-stage renal disease. The resident's care plan included specific interventions for nutritional management, and the physician's orders required the administration of Lansoprazole via G-tube daily. However, the medication observed in the storage room was expired, and it was discovered that the medication had been signed off as administered on multiple occasions in May, despite the expiration date being prominently marked on the bottle. Interviews with staff revealed discrepancies in medication administration. An LPN admitted to signing off the medication as administered without actually doing so, and the DNS acknowledged awareness of the issue. The facility's policy mandates that medications be administered according to orders, with checks for the right medication, dosage, time, and expiration date. The failure to adhere to these protocols resulted in the medication not being administered as required, despite being documented as such in the MAR.
Expired Medications Found in Facility's Medication Room
Penalty
Summary
The facility failed to store medications appropriately in one of the sampled medication rooms, as observed during a survey. Several expired medications were identified in Station 4's medication room, including Ipatropium Bromide/Albuterol Sulfate and Albuterol Sulfate inhalation solutions, as well as a compounded Lansoprazole suspension. These medications were found to be expired, yet they remained stored in the medication room. An LPN acknowledged that it was the responsibility of all staff to regularly check for expired medications and ensure they are returned to the pharmacy or placed in a designated return bin. The review of the Medication Administration Record (MAR) revealed that the expired Lansoprazole suspension had been administered to a resident on multiple occasions. The pharmacist confirmed that the efficacy of the compounded Lansoprazole would diminish after its expiration date, and no refill requests were found in the system. The facility's medication storage policy clearly states that discontinued, outdated, or deteriorated drugs should not be used and must be returned or destroyed, which was not adhered to in this instance.
Failure to Identify and Cohort Residents with MDRO
Penalty
Summary
The facility failed to properly identify and maintain records of residents with known multidrug-resistant organism (MDRO) colonization and did not appropriately cohort residents with these infections. Resident #42 was admitted with diagnoses including MRSA and C-diff colonization, and the care plan included monitoring for signs and symptoms of these infections. However, the facility's Enhanced Barrier and MDRO log did not reflect Resident #42's history of MRSA and C-diff. Similarly, Resident #230, who had a history of ESBL E.coli, was not identified in the MDRO log. Both residents were sharing a room, which was against the facility's policy of cohorting residents with the same MDRO or with those at low risk of acquiring the infection. The Director of Nursing Services (DNS) and the Infection Preventionist Nurse (LPN #8) acknowledged the oversight, noting that the bed board and MDRO log were not updated to reflect the residents' MDRO histories. The facility's practice was to update the MDRO log daily after reviewing admission records, laboratory results, and daily reports, but this was not done in these cases. The DNS and LPN #8 admitted that residents with the same infections should be cohorted together or with residents at low risk, as per the facility's policy, which was not followed in this instance.
Failure to Timely Complete MDS Assessments
Penalty
Summary
The facility failed to ensure that quarterly Minimum Data Set (MDS) assessments for three residents were completed and submitted within the prescribed timing parameters. Resident #25 had an admission MDS assessment with a completion date of 12/13/23, and the subsequent quarterly assessment was due by 3/23/24 but was completed 40 days late on 5/2/24. Resident #104's annual MDS assessment was completed 11 days late on 12/20/23, and the quarterly assessment due by 3/11/24 was completed 58 days late on 5/8/24. Resident #170's admission MDS assessment was completed on 11/27/23, and the quarterly assessment due by 3/12/24 was completed 51 days late on 5/2/24. The MDS Coordinator, identified as LPN #1, acknowledged responsibility for the completion of the MDS assessments and admitted to being late in completing and submitting the quarterly MDS assessments for the residents mentioned. LPN #1 noted that there was a period when only two MDS Coordinators were available for the facility, which contributed to the delay in completing the assessments. The Resident Assessment Instrument 3.0 user manual specifies that the resident's assessment must be completed no later than 14 calendar days after the assessment reference date to be considered timely.
Failure to Complete Annual Performance Evaluations for Nurse Aides
Penalty
Summary
The facility failed to complete annual performance evaluations for two of three sampled nurse aides, specifically NA #1 and NA #3. This deficiency was identified through a review of personnel files, facility policy, and interviews. NA #1 was hired on August 10, 2012, and NA #3 on July 7, 1999. During an interview with HR on May 10, 2024, it was revealed that performance evaluations for the years 2022 and 2023 could not be located for these nurse aides. The HR representative noted that these evaluations are typically completed by the unit manager, but recent turnover has resulted in the evaluations not being completed. Further interviews with the Director of Nursing Services (DNS) on the same day indicated that only annual competencies were being completed, not performance evaluations. The facility's policy, titled 'Competency of Nursing Personnel,' directs that evaluations be done at intervals determined by Nursing Administration for performance issues or attendance, but no policy requiring annual performance reviews for nurse aides was provided when requested.
Failure to Transcribe Critical Medication on Admission
Penalty
Summary
The facility failed to transcribe a critical medication, Levothyroxine, for a newly admitted resident diagnosed with hypothyroidism. The resident's Inter-Agency Referral Report directed the administration of Levothyroxine 100 mcg daily, but this order was omitted during the transcription process. The resident did not receive the medication for 27 days, from admission until discharge. The omission was discovered by the resident's spouse after discharge, who noticed the medication was missing from the discharge paperwork. Subsequent bloodwork showed elevated thyroid-stimulating hormone (TSH) levels, indicating the resident's thyroid condition was not managed during the stay. The error occurred because the 7AM-3PM Unit Manager, RN #1, was distracted by a personal phone call while transcribing the admission orders. The facility's protocol required a second and third check of the orders by the 11PM-7AM Nursing Supervisor and the 7AM-3PM Unit Manager or Quality Assurance Nurse, respectively. However, these checks failed to catch the omission. Interviews with the involved staff confirmed the lapses in the transcription and verification processes, leading to the resident missing 27 doses of Levothyroxine.
Failure to Obtain Ordered Laboratory Blood Work
Penalty
Summary
The facility failed to implement a physician's order to obtain laboratory blood work for a newly admitted resident diagnosed with malignant neoplasm of the bladder, pancreatic adenocarcinoma, chronic anemia, hypomagnesemia, and hypokalemia. A physician's progress note and order dated 7/25/23 directed the facility to draw a Complete Blood Count (CBC) and Comprehensive Metabolic Panel (CMP) on 7/27/23. However, a review of the clinical record and facility documentation revealed that the CBC and CMP were not obtained as ordered. Interviews with the Advanced Practice Registered Nurse (APRN) and the Director of Nurses (DON) confirmed the absence of the laboratory results and the lack of documentation explaining why the blood work was not performed.
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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.
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Nursing homes near New Britain
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Amberwoods Of Farmington | 1.1 mi | ★★★★★ | 2 | 0 |
| Autumn Lake Healthcare At West Hartford | 2 mi | ★★★★★ | 21 | 0 |
| Monsignor Bojnowski Manor, Inc | 2.9 mi | ★★★★★ | 3 | 0 |
| Jefferson House | 3.1 mi | ★★★★★ | 0 | 0 |
| Bel-air Manor Nursing & Rehabilitation Center | 3.4 mi | ★★★★★ | 0 | 0 |
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