Autumn Lake Healthcare at Cromwell

In the surveyor’s words

From the most serious findings on record at Autumn Lake Healthcare at Cromwell, in the surveyor’s own words.

• Actual harm, isolatedF697Apr 2, 2026

  Based on observation, interview, record review, and facility policy review, the facility failed to ensure timely assessment and management of pain for 1 of 1 resident (Resident #1) reviewed for pain, when staff did not communicate the resident's report of severe pain to the licensed nurse and failed to ensure timely access to and administration of prescribed PRN pain medication.This resulted in Resident #1 experiencing unrelieved severe pain (rated 8/10 and described as unbearable) for approximately 1 hour and 45 minutes, accompanied by observable signs of distress, including facial grimacing, restlessness, and inability to reposition comfortably, as well as verbalized psychosocial distress.The failure occurred when (1) the nurse aide did not report the resident's complaints of pain to the… […]

• No harm, potential for more than minimal, widespreadF812Jul 25, 2024

  Based on the tour of the Dietary Department, staff interviews, facility documentation, and facility policy, the facility failed to ensure open food items were dated to include dates opened/expired/use by and failed to ensure food was served under sanitary conditions. The findings include: Tour of the kitchen with the Dietary Manager on [DATE] at 10:56 AM identified the following: a. The threshold of the walk in refrigerator where the door meets the doorframe had a heavy accumulation of dust and debris. Interview with the Dietary Manager identified that floors were swept after every meal service. b. An opened package containing 5 hotdogs was wrapped in plastic wrap but failed to identify an open date or expiration date. c. […]

• No harm, potential for more than minimal, widespreadF851Jul 25, 2024

  Based on interview and review of facility documentation, the facility failed to ensure that Payroll Based Journal (PBJ) data (staffing information) for the third quarter (April, May, and June 2023) was submitted as required by the Centers for Medicare and Medicaid Services (CMS). The findings Include: Interview and review of facility documentation with the Administrator on 7/25/24 at 10:30 AM identified that he was aware that PBJ data for the third quarter of 2023 had not been submitted. The Administrator further indicated that the facility's corporate office was responsible for submitting PBJ data to CMS, however had failed to submit the information as required. […]

• No harm, potential for more than minimal, patternF603Apr 2, 2026

  Based on observations, review of the clinical record, facility policy and interviews for 3 of 3 sampled residents (Resident #30, Resident #34, and Resident #69) residing on the secure unit, the facility failed to ensure a systematic way of determining placement, continued placement, involvement by the physician, resident representative, interdisciplinary team, or the impact residing on a secure unit had on the residents. The findings include:1. Resident #30 's diagnoses included Alzheimer's dementia early onset, anxiety disorder, and epilepsy.A wander risk assessment dated [DATE] identified a high risk for wandering.The admission Minimum Data Set assessment dated [DATE] identified Resident #30 was severely cognitively impaired with short- and long-term memory problems, fluctuations in… […]

• No harm, potential for more than minimal, patternF584Jul 25, 2024

  Based on observations, interviews, and review of facility documentation, for 4 of the rooms/resident areas on the Elm Unit, 7 of the rooms/resident areas on the Maple Unit, 9 of the rooms/resident areas on the Oak Unit, and 2 of the rooms/resident areas on the Hickory Unit, the facility failed to ensure the residents' rooms and furnishing were maintained in a clean, safe, homelike and sanitary manner and in good repair. The findings included: 1. On 07/19/24 and 07/24/24, observations throughout the day of the Bathroom between rooms [ROOM NUMBERS] on the Elm Unit identified the following: a. The surface of the wall underneath the sink had the drywall and tile removed. The plumbing and wall studs were exposed with tile debris falling from the wall. […]