Deficiency Records for Autumn Lake Healthcare at West Hartford
Updated as of April 01, 2024
A list of the most recent deficiencies for Autumn Lake Healthcare at West Hartford. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2024-02-06 | 2024-03-13 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2024-02-06 | 2024-03-13 | N |
| Ensure each resident receives an accurate assessment. | Health | 2024-02-06 | 2024-03-13 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2024-02-06 | 2024-03-13 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-02-06 | 2024-03-13 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2024-02-06 | 2024-03-13 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-02-06 | 2024-03-13 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2024-02-06 | 2024-03-13 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-02-06 | 2024-03-13 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-02-06 | 2024-03-13 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-02-06 | 2024-03-13 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-02-06 | 2024-03-13 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2024-02-06 | 2024-03-13 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2024-02-06 | 2024-03-13 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2024-02-06 | 2024-03-13 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2024-02-06 | 2024-03-13 | N |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2024-02-06 | 2024-03-13 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-02-06 | 2024-03-13 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-02-06 | 2024-03-13 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-02-06 | 2024-03-13 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2024-02-06 | 2024-03-13 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2024-02-06 | 2024-03-13 | N |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2024-02-06 | 2024-03-13 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2024-02-06 | 2024-03-13 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-01-31 | 2024-02-28 | N |
| Meet requirements for the installation and maintenance of medical gas and medical vacuum systems. | Fire Safety | 2024-01-31 | 2024-02-28 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-01-31 | 2024-02-28 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2023-09-14 | 2023-10-10 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-09-14 | 2023-10-10 | Y |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2023-09-14 | 2023-10-10 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-09-14 | 2023-10-10 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-09-14 | 2023-10-10 | Y |
| Observe each nurse aide's job performance and give regular training. | Health | 2023-09-14 | 2023-10-10 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2023-09-14 | 2023-10-10 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-09-14 | 2023-10-10 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-09-13 | 2022-10-22 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-07-21 | 2022-08-30 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2022-07-21 | 2022-08-30 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-07-21 | 2022-08-30 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2022-07-21 | 2022-08-30 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-07-21 | 2022-08-30 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-07-21 | 2022-08-30 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-05-06 | 2022-06-21 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-05-06 | 2022-06-21 | Y |
| Address patient/client population and determine types of services needed. | Fire Safety | 2021-10-04 | 2022-01-05 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2021-10-04 | 2022-01-05 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2021-10-04 | 2022-01-05 | N |
| Establish staff and initial training requirements. | Fire Safety | 2021-10-04 | 2022-01-05 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-10-04 | 2022-01-05 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-10-04 | 2022-01-05 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-10-04 | 2022-01-05 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-10-04 | 2022-01-05 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2021-10-04 | 2022-01-05 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-10-04 | 2022-01-05 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-10-04 | 2022-01-05 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-10-04 | 2022-01-05 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-10-13 | 2021-11-22 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-10-13 | 2021-11-22 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-10-13 | 2021-11-22 | N |
| Respond appropriately to all alleged violations. | Health | 2021-10-13 | 2021-11-22 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-10-13 | 2021-11-22 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-10-13 | 2021-11-22 | N |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2021-10-13 | 2021-11-22 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-10-13 | 2021-11-22 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-10-13 | 2021-11-22 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2021-10-13 | 2021-11-22 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2021-10-13 | 2021-11-22 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-10-13 | 2021-11-22 | N |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2021-10-13 | 2021-11-22 | Y |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2021-10-13 | 2021-11-22 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-10-13 | 2021-11-22 | Y |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2021-10-13 | 2021-11-22 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2021-08-08 | 2021-09-01 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-05-09 | 2019-06-20 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-05-09 | 2019-06-20 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2019-05-09 | 2019-06-20 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2019-05-09 | 2019-06-20 | N |
