Autumn Lake Healthcare at West Hartford

Inspectors wroteBased on clinical record review, facility documentation, facility policies, and interviews, for one (1) of three (3) sampled residents (Resident #1) reviewed for pain management, the facility failed to ensure ongoing assessment, implementation of additional interventions, and provider notification when Resident #1 continued to report severe unrelieved pain following administration of prescribed pain medication. The failures included lack of reassessment, failure to administer available as needed (PRN) pain medication, and failure to notify the provider when pain remained unchanged.

Inspectors wroteBased on clinical record review, facility documentation, facility policies, and interviews, for one (1) of three (3) residents (Resident #1) reviewed for medication administration, the facility failed to ensure Resident #1's Schedule II pain medication was available for administration in accordance with the physician order. For two (2) of eleven (11) residents (Resident #2 and Resident #3) reviewed for medication administration, the facility failed to document the administration of a controlled substance in accordance with facility policy and failed to remove a controlled substance from the medication cart after the order expired.

Inspectors wroteBased on clinical record review, facility documentation, facility policies, and interviews, for one (1) of three (3) residents (Resident #1) reviewed for medication administration, the facility failed to ensure the physician's order for a Schedule II controlled substance was followed. The failures included unapproved substitution of medications, inaccurate documentation on the Controlled Substance Disposition Record, and inaccurate documentation on the Medication Administration Record (MAR).

Inspectors wroteBased on clinical record review, observations, interviews, and facility documentation, the facility failed to ensure discontinued Schedule II through V controlled substances brought into the facility from an outside pharmacy and stored in bubble packs and bottles were secured in a permanently affixed, separately locked compartment as required.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy and interview for 2 residents (Resident #41 and 58) reviewed for abuse, the facility failed to ensure the residents were treated in a respectful and dignified manner.

Inspectors wroteBased on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 5 residents (Resident # 55) reviewed for accidents, the facility failed to conduct an assessment to ensure the resident could safely self-administer medications.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 2 residents (Resident #2) reviewed for food and on a restricted diet, the facility failed to provide the resident with his/her choice of meals.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interview for 1 of 3 residents (Resident #1) reviewed for hospitalization, the facility failed to ensure the physician was immediately notified when the resident had of a change in condition including difficulty with speech and right sided weakness and for 1 of 5 residents (Resident #7) reviewed for accidents, the facility failed to ensure that the physician and resident representative were notified of newly identified skin issues.

Inspectors wroteBased on review of facility documentation, facility policy and interviews for 1 of 3 sampled nurse aide and 1 of 2 licensed staff employee files, the facility failed to ensure criminal background checks were completed prior to the employee starting employment and caring for residents in the facility.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interview for 1 of 5 residents (Resident #2) reviewed for PASARR, the facility failed to review the PASARR on admission for accuracy and failed to update the state designated authority when the resident received a new diagnosis of major depression.

Inspectors wroteBased on observation, review of the clinical record, facility documentation, facility policy, and interview for 1 of 5 residents (Resident #7) reviewed for accidents, the facility failed to ensure that the care plan was revised to reflect identified skin issues.

Inspectors wroteBased on observation, review of the clinical record, facility policy, and interviews for 1 of 2 residents (Resident #20) reviewed for activities of daily living (ADLs), the facility failed to assist the resident out of bed upon his/her request.

Inspectors wroteBased on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 5 residents (Resident # 7) reviewed for accidents, the facility failed to ensure that an RN assessment was completed following newly identified skin issues on the resident's face, and failed to ensure weekly body audits were completed per the physician's order, and for 1 of 3 residents (Resident #1) reviewed for hospitalization, the facility failed to ensure a comprehensive RN assessment was completed and documented upon the identification of a change in condition.

Inspectors wroteBased on review of the clinical record, facility policy, and interview for 1 of 3 residents (Resident # 52) reviewed for pressure ulcers, the facility failed to ensure weekly skin audits were completed per the facility policy and failed to ensure a comprehensive RN assessment was completed upon the identification of a new skin issue.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for 2 of 2 residents (Resident #2 and 21) reviewed for a specialty medical procedure and who were on a fluid restriction, the facility failed to monitor the resident's fluid intake to include 24-hour totals.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy and interview for 1 resident (Resident #4) reviewed for dental services, who required an extraction of a tooth and was receiving Eliquis (a blood thinner), the facility failed to hold the Eliquis which resulted in a delay in having the tooth extracted.

Inspectors wroteBased on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 3 residents (Resident #11) reviewed for pressure ulcers, the facility failed to ensure that staff adhered to enhanced barrier precautions (EBP) when providing care to the resident, and for 2 of 4 medication carts, the facility failed to ensure the medication carts were maintained in a clean and sanitary manner.

Inspectors wroteBased on observation, review of the clinical record, review of facility documentation, review of facility policy, and interviews for 1 resident (Resident #1) reviewed for ADLs, the facility failed to ensure weekly skins were performed in accordance with facility policy.

Inspectors wroteBased on observations, clinical record review, facility documentation review, facility policy review, and interviews for 2 of 43 residents (Resident #1 and Resident #3) reviewed for ADL care, the facility failed to ensure facility staffing was utilized across the facility to ensure residents received personal care and incontinent care in a timely manner.

Inspectors wroteBased on record review, facility documentation, and staff interviews for one of three residents (Resident #1), reviewed for quality of care, the facility failed to ensure daily weights were obtained and failed to notify the physician of a weight gain greater in accordance with physician orders.

Inspectors wroteBased on clinical record review, facility documentation review, facility policy review, and interviews for one resident of three residents (Resident #1) reviewed for quality of care, the facility failed to ensure staff coverage timely to ensure a blood sugar measurement was obtained prior to a meal in accordance with physician orders.

Inspectors wroteBased on review of clinical records, facility documents, and interviews for one (1) of (3) residents (Resident #2), reviewed for hydration, the facility failed to notify the Advanced Practice Registered Nurse (APRN) that an order was not promptly initiated .

Inspectors wroteBased on review of clinical record and facility documentation for one resident (Resident #1) reviewed for meal intake, the facility failed to document daily food consumption.

Inspectors wroteBased on clinical record reviews, observations, review of facility policy and staff interviews for 3 of 5 residents reviewed for care planning for (Resident # 31), the facility failed to develop a person-centered care plan for the resident medication and for( Resident # 41), the facility failed to develop a comprehensive care plan regarding the resident's respiratory treatment and discharge needs and for( Resident # 66), the facility failed to develop a discharge care plan to address the residents needs post discharge.

Inspectors wroteBased on clinical record reviews, facility policy and interviews for 1 of 1 resident ( Resident # 8) reviewed for call bell , the facility failed to ensure the resident's call bell was within reach per facility practice and plan of care and for 7 of 10 sampled residents (Residents # 8, 32, 35, 39, 50, 52 and 53) reviewed for Care Plans, the facility failed to review and/or revise care plans in a timely manner.

Inspectors wroteBased on review of the clinical records, review of policy and interviews for 1 of 3 residents (Resident #2) observed dining, the facility failed to clarify a physician's diet order for a resident who had 2 active orders and for 2 of 3 residents ( Resident # 52) who require assistance with medication administration, the facility failed to monitor the resident's blood pressure as prescribe and for (Resident # 53), the facility failed to clarify and administer treatment orders and for 1 of 5 residents ( Resident # 57) reviewed for Unnecessary Medication, the facility failed to administer an antidepressant medication as prescribed. and for 1 of 2 (Resident # 117) reviewed for accidents, the facility failed to conduct assessments to meet professional standards.

Inspectors wroteBased on observations of the noon meal, interviews, test tray for palatability and staff interviews for 3 out 5 residents screened for dining (Resident #5, Resident #29, Resident #31), the facility failed to ensure that food was appetizing, and palpable to taste.

Inspectors wroteBased on observations of the kitchen, facility policy and interviews, the facility failed to properly label opened packaged food items/individual servings, remove expired foods and to perform hand hygiene after touching face with gloved hand to prevent cross contamination.

Inspectors wroteBased on observations of the kitchen, the facility policy, and staff interviews, the failed to ensure dietary staff covered facial hair with a hairnet while in the kitchen and failed to ensure staff handled linen to prevent the spread of infection and reviewed of the facility Infection Control Program identified the facility failed to provide infection surveillance per policy and adhere to the legionella water management program per policy .

Inspectors wroteBased on review of facility documentation and interviews, the facility failed to ensure all staff received Abuse and Dementia training annually since the last survey.

Inspectors wroteBased on review of facility documentation and interviews, the facility failed to ensure NA nurse aides received the required 12 hours of training annually since the last survey.

Inspectors wroteBased clinical record, observation, facility documentation review, policy review and interviews for 1 of 1 sampled resident (Resident #41) reviewed for Resident Assessments, the facility failed to ensure the resident's admission assessment included a specialized respiratory treatment and ensure care areas were triggered as part of the comprehensive assessment.

Inspectors wroteBased on clinical record reviews, facility policy and interviews for 2 of 2 sampled residents (Residents #29 and 39) reviewed for Care Planning, the facility failed to complete the cognitive and mood care areas of the Minimum Data Set assessments per facility policy.

Inspectors wroteBased on clinical record reviews, facility policy and interviews for 1 of 2 sampled residents (Resident #39) reviewed for Preadmission Screening and Resident Review (PASRR), the facility failed to update the level of care in a timely manner.

Inspectors wroteBased on clinical record review, review of facility policy and interviews for 1 of 3 residents (Resident #41) reviewed for discharge, the facility failed to ensure the clinical record identified the resident's discharge plans post discharge from the facility.

Inspectors wroteBased on clinical record reviews, facility policy and interviews for 2 of 3 residents (Resident #52, Resident #57) who required assistance with medication administration, the facility failed to ensure physician's orders were followed as prescribed.

Inspectors wroteBased on clinical record review, observation, review of facility policy and interviews for 1 of 1 resident (Resident #53), at risk for pressure ulcer development, the facility failed to appropriately identify the residents wound treatment.

Inspectors wroteBased observations of dining and the environment, policy review and interviews for 3 of 3 residents (Resident #2, Resident #31, Resident #57) observed during dining, the facility failed to ensure the residents had a way to access staff in case of a choking incident to ensure residents were free from accidents and the facility failed to consistently monitor hot water temperatures per practice and as directed to ensure safe and acceptable water temperatures.

Inspectors wroteBased on clinical record, observation, policy review and interviews for 1 of 1 sampled resident (Resident #41) reviewed for respiratory care, the facility failed to ensure the resident had a physician's order for the utilization of oxygen and failed to implement a sleep device for sleep apnea.

Inspectors wroteBased on clinical record review, observation, review of facility policy and interview for 1 of 1 resident (Resident #32) reviewed for specialized treatment, the facility failed to consistently conduct weights per physician's orders and failed to provide ongoing communication and collaboration with the specialized treatment center regarding care and services consistent with facility policy and the plan of care.

Inspectors wroteBased on clinical record reviews, observations, facility policy and interviews for 2 of 5 residents reviewed during medication administration (Resident #72 and #119), the facility failed to ensure the residents received the prescribe dose to ensure the facility's medication error rate was less than 5 percent.

Inspectors wroteBased on observation, interviews, and review of facility policy, the facility failed to ensure Level 3 medications were stored in a locked box and failed to discard expired medications.

Inspectors wroteBased on observation, interviews, and the facility policy the facility failed to ensure snacks were consistently offered to all residents in the afternoon and prior to bedtime.

Inspectors wroteBased on record review, review of facility policy and interview for 1 of 1 resident (Resident # 31) reviewed for anticoagulant use, the facility failed to ensure laboratory results related to Coumadin(anticoagulant) use was available in the resident's clinical record.

Inspectors wroteBased on review of the clinical record, review of facility policy and interview for 1 of 2 residents (Resident # 117) reviewed for accidents, the facility failed to ensure a bathroom emergency call bell system allow residents to call for staff assistance during a potential fall.

Inspectors wroteBased on interviews and staff interviews, the facility failed to ensure residents knew how to file grievance and the location of the grievance form.

Inspectors wroteBased on clinical record review, facility documentation, emergency medical technician report, facility policy, and interviews, for one (1) resident, (Resident #1), the facility failed to provide Cardio-Pulmonary Resuscitation (CPR) in accordance with the resident's request and physician's order for full code (resuscitation procedures will be provided including but not limited to CPR) resulting in a finding of Immediate Jeopardy.

Inspectors wroteBased on clinical record review, facility documentation, facility policy and interviews for one (1) of three (3) residents reviewed for advanced directives, (Resident #1), the facility failed to ensure the Advanced Directive was addressed upon admission to the facility in accordance with facility policy.

Inspectors wroteBased on clinical record review, facility documentation, facility policy and interviews for one (1) of three (3) residents, (Resident #1), who was reviewed for a change in condition, the facility failed to ensure a Registered Nurse (RN) assessment was completed when a resident experienced a change in condition.

Inspectors wroteBased on clinical record reviews, facility documentation, facility policy and interviews for one sampled resident (Resident #2) who was reviewed for a medication error, the facility failed to ensure Resident #2's insulin was readily available to prevent two doses from being omitted, the facility failed to ensure the physician was notified when the Insulin was not available and failed to ensure the resident's blood glucose was monitored per the physician's order.

Inspectors wroteBased on clinical record review, facility documentation, facility policy, and interviews for one of three residents, (Resident #1), who required oxygen therapy, the facility failed to obtain a physician's order for oxygen administration.

Inspectors wroteBased on review of employee files, interviews, and policy, for five of five Nurse Aide (Nurse Aide #1, #2, #3, #4, and #5) who were reviewed for performance evaluations, the facility failed to ensure that yearly evaluations were completed.

Inspectors wroteBased on facility documentation review, facility policy review, and interviews for facility Administration review, the facility failed to ensure the facility administered its resources effectively and to ensure effective administrative oversight of staff and resident care timely to maintain the highest practicable physical, mental, and psychosocial well-being of residents.

Inspectors wroteBased on clinical record review, facility documentation, facility policy and interviews for one (1) of three (3) residents, (Resident #1), reviewed for medication administration the facility failed to document in the clinical record when the medication was administered in accordance with standards of practice.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, CDC guidance and interviews for 2 residents (Resident #24 and 499) reviewed for skin conditions, the facility failed to ensure that the registered nurse assessed a new rash and/or skin condition on admission and when it deteriorated, documented the assessments and communicated those assessment timely to the physician.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident # 499) reviewed for pressure ulcers, the facility failed to complete weekly skin assessment with measurements for a resident with known pressure injuries in a timely manner and failed to ensure a nutritional assessment addressed the needs of a newly admitted resident with identified pressure injuries in a timely manner.

Inspectors wroteBased on observations, review of the clinical record, facility documentation, facility policy and interview for 1 resident (Resident #24) the facility failed to place Resident #24 on isolation precautions according to professional standards and facility policy, and for 3 of 5 residents (Resident #4, 149 and 153) who were recently admitted to the suspected COVID-19 unit, the facility failed to ensure isolation signs were posted and isolation bins with supplies were available outside the door according to policy, and for 1 resident (Resident #499) reviewed for pressure ulcers, the facility failed follow infection control practices with regard to hand hygiene during wound care and the facility failed to ensure all staff were screened prior to entering the facility.

Inspectors wroteBased on clinical record reviews, review of facility documentation, facility policy and interviews for one of three sampled residents (Resident #15) who were reviewed for missing personal property, the facility failed to ensure an inventory list was completed upon the resident's admission or during an emergency transfer to another long-term care facility and failed to safeguard the resident's personal property during the time the resident was temporarily relocated.

Inspectors wroteBased on observation, review of the clinical record, facility policy, facility documentation, and interviews for 6 residents (Resident #2, 23, 24, 30, 299 and 499) reviewed for notification of change, the facility failed to notify the physician and responsible representatives when required.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 2 residents (Resident #23) reviewed for an allegation of abuse, the facility failed to ensure the resident was free from verbal abuse and the facility failed to protect the resident for 6 days after the incident.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 2 residents (Resident #30) reviewed for an allegation of abuse, the facility failed to report the allegation according to established requirements.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 2 residents (Resident #30) reviewed for an allegation of abuse, the facility failed to immediately start an investigation according to established requirements.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 3 residents (Resident #499) reviewed for falls, the facility failed to develop a comprehensive care plan for a resident at risk for falls, who later sustained a fall. Resident #499 was admitted on [DATE] with diagnoses that included peripheral vascular disease, protein calorie nutrition and heart failure. A fall assessment dated [DATE] identified Resident #499 was at risk for falls. The MDS dated [DATE] identified Resident #499 had moderately impaired cognition and a history off falling prior to admission. The care plan dated 9/20/21 identified Resident #499 required assistance with ADL care with interventions that included extensive assistance for bed mobility, transfers and toileting. [...]

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for 2 residents (Resident #17 and 26) reviewed for person centered care planning and timing, the facility failed to ensure there were interdisciplinary care plan meetings held timely.

Inspectors wroteBased on clinical record review and staff interview for one of five sampled resident who utilized a CPAP respiratory device, the facility failed to identify when resident ' s CPAP device was discontinued by a physician and failed to ensure an assessment was conducted after the Continuous Positive Airway Pressure (CPAP) device was discontinued to meet professional standards of practice.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 3 Resident (Resident #17) reviewed for Code Status, the facility failed to ensure the code status were the wishes of the resident or resident representative.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 5 residents (Resident # 21) reviewed for unnecessary medications, the facility failed to respond to a pharmacy recommendation. Resident #21 was admitted on [DATE] with diagnoses that included Alzheimer's disease, anxiety and insomnia. The initial 48-hour care plan resident care plan dated 8/11/21 identified impaired/decline in cognitive function Alzheimer's disease with interventions that included observe and evaluate types of changes in cognitive status such as confusion, orientation, forgetfulness, and notify physician as needed. Physician's order dated 8/11/21 directed to administer trazadone 25mg every 8 hours as needed for agitation without a 14-day documented expiration date. [...]

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 5 residents (Resident #21) reviewed for unnecessary medications, the facility failed to ensure an initial PRN (as needed) order for a psychotropic medication was limited to 14 days according to policy.

Inspectors wroteBased on review of the clinical record, facility documentation and staff interviews for 1 of 3 residents (Resident #50), reviewed for abuse, the facility failed to ensure that all staff received re-education regarding customer service after an allegation of rough handling to prevent potential future abuse.

Inspectors wroteBased on clinical record reviews, review of facility documentation, facility policy and interviews for one of three sampled residents (Resident #15) who were reviewed for missing personal property, the facility failed to resolve a grievance regarding missing personal property.