Inspection Report Summary
The most recent inspection on September 17, 2025, found no deficiencies during a complaint investigation. Earlier inspections generally showed a pattern of no violations, with multiple complaint investigations in 2024 and 2025 also substantiating no deficiencies. Prior to that, the facility had citations mainly related to resident care documentation, infection control, and environmental safety issues, particularly during 2019 and 2020, including deficiencies in fall risk management, pressure ulcer care, and COVID-19 protocols. Complaint investigations were mostly unsubstantiated in recent years, with one substantiated Class A occurrence related to reporting an attempted suicide in 2019. The inspection history indicates improvement over time, with no deficiencies noted in the most recent reports after earlier periods of cited issues.
Deficiencies (last 6 years)
Deficiencies are regulatory violations found during state inspections.
Deficiencies per year
Census
Based on a September 2025 inspection.
Census over time
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Chaim Scher | Administrator | Personnel contacted during the inspection. |
| Tanya Hopkins | Director of Nursing | Personnel contacted during the inspection. |
| Deborah Smith | RN, NC | Report submitted by. |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Chaim Scher | Administrator | Personnel contacted during the inspection |
| Tanya Hopkins | DON | Personnel contacted during the inspection |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Michelle Morrison | Regional Nurse | Personnel contacted during the inspection. |
| Connie Vumback | RN | Report submitted by. |
Inspection Report
RenewalInspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Chaim Scher | Administrator | Personnel contacted during the inspection. |
| Tanya Hopkins | DNS | Personnel contacted during the inspection. |
| Monika Ahlers | ADON | Personnel contacted during the inspection. |
| Deborah Smith | RN, NC | Report submitted by. |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Chaim Scher | Administrator | Personnel contacted during the inspection. |
| Tanya Hopkins | DNS | Personnel contacted during the inspection. |
| Monika Ahlers | ADON | Personnel contacted during the inspection. |
| Deborah Smith | RN, NC | Signature of FLIS Staff and report submitter. |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Chaim Scher | Administrator | Personnel contacted during inspection |
| Tanya Hopkins | DNS | Personnel contacted during inspection |
Inspection Report
Renewal| Name | Title | Context |
|---|---|---|
| Chaim Scher | Administrator | Personnel contacted during the inspection. |
| Tonya Hopkins | DNS | Personnel contacted during the inspection. |
Inspection Report
Renewal| Name | Title | Context |
|---|---|---|
| Tonya Hopkins | DNS | Personnel contacted during the inspection. |
| Chaim Scher | Administrator | Personnel contacted during the inspection. |
Inspection Report
Renewal| Name | Title | Context |
|---|---|---|
| Chain Scher | Administrator | Personnel contacted during the inspection |
| Tonya Hopkins | DNS | Personnel contacted during the inspection |
Inspection Report
Plan of Correction| Name | Title | Context |
|---|---|---|
| Cher Michaud | Supervising Nurse Consultant | Named in complaint investigation and correspondence |
| Ana McBrat | Director of Nursing (DNS) | Interviewed regarding fall and pressure ulcer findings |
| Lisa Walles | Infection Control Nurse (ICN) | Interviewed regarding COVID-19 outbreak testing and infection control |
| Sandra Vermont-Hollis | Supervising Nurse Consultant | Signed notice of noncompliance letter |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Cher Michaud | Supervising Nurse Consultant | Signed the notice letter and involved in the Facility Licensing and Investigations Section. |
| Director of Nurses | Interviewed multiple times regarding findings related to falls, pressure ulcers, weight loss, and infection control. | |
| Advanced Practice Registered Nurse | Conducted assessments and gave orders related to pressure ulcers and weight loss. | |
| Licensed Practical Nurse #1 | Interviewed regarding resident abuse incident and staff breakroom access. | |
| Maintenance Director | Interviewed regarding safety check of coffee pot in staff breakroom. | |
| Infection Control Nurse | Interviewed regarding infection control practices and COVID-19 testing. | |
| Dietary Aide #1 | Observed with mask hanging off ear and interviewed about mask use in kitchen. | |
| Therapeutic Recreation Director | Interviewed regarding mask use during activity. | |
| Nurse Aide #1 | Observed speaking to unmasked resident and interviewed about mask use. | |
| Employee #1 | Had a temperature of 102 degrees and tested positive for COVID-19. |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #2 | LPN | Named in medication notification deficiency for Resident #1. |
| Licensed Practical Nurse #1 | LPN | Charge nurse on duty when Resident #1 passed away; involved in documentation deficiency. |
| Nurse Aide #1 | NA | Failed to wear surgical mask properly while providing care to Resident #2. |
| Director of Nurses | DNS | Provided statements regarding documentation and infection control deficiencies. |
| Assistant Director of Nurses | ADNS | Observed mask non-compliance and directed corrective action. |
Inspection Report
Abbreviated SurveyInspection Report
Complaint InvestigationInspection Report
Monitoring| Name | Title | Context |
|---|---|---|
| Sandra Vermont-Hollis | Supervising Nurse Consultant | Signed letter as Supervising Nurse Consultant for Facility Licensing and Investigations Section |
| Jessica Garcia | Administrator | Administrator of Autumn Lake Healthcare At Cromwell addressed in the letter |
Inspection Report
Abbreviated Survey| Name | Title | Context |
|---|---|---|
| Acting Director of Nurses | Donning N95 mask improperly | |
| LPN #1 | Licensed Practical Nurse | Did not offer masks to dementia unit residents |
| LPN #2 | Licensed Practical Nurse | Described gown and face shield storage and use |
| Infection Preventionist | Identified contamination risks with gown and face shield storage and improper masking | |
| DNS | Director of Nursing Services | Interviewed about resident masking and social distancing |
Inspection Report
Abbreviated SurveyInspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Chaim Scheer | Administrator | Named in relation to findings about resident transfer communication. |
| Gina Jones-Blue | Director of Nursing (DON) | Named in relation to findings about resident transfer communication. |
| Heidi Caron | Supervising Nurse Consultant | Signed complaint investigation letter. |
| Jessica Garcia | Administrator | Named in follow-up complaint investigation and related correspondence. |
| Judy Birtwistle | Supervising Nurse Consultant | Signed follow-up complaint investigation letter. |
| Kafaytou Afolabi | Director of Nursing Services (DNS) | Named in relation to inspection findings and interviews. |
Inspection Report
Plan of Correction| Name | Title | Context |
|---|---|---|
| Heidi Caron | Supervising Nurse Consultant | Signed letter regarding plan of correction and deficiencies |
| Jessica Garcia | Facility representative addressed in the letter |
Inspection Report
Plan of Correction| Name | Title | Context |
|---|---|---|
| Judith Birtwistle | Supervising Nurse Consultant | Signed letter regarding complaint investigation and plan of correction |
Inspection Report
Annual Inspection| Name | Title | Context |
|---|---|---|
| Food Service Director (FSD) | Interviewed regarding kitchen sanitation deficiencies and food safety | |
| Registered Nurse #1, Infection Control Nurse (ICN) | Interviewed regarding use of nourishment room as staff break room and infection control concerns | |
| Administrator | Interviewed regarding facility remodeling and water management plan deficiencies | |
| Maintenance Director | Interviewed regarding facility maintenance issues and water management plan deficiencies |
Inspection Report
Plan of Correction| Name | Title | Context |
|---|---|---|
| Connie Greene | Supervising Nurse Consultant | Signed the plan of correction letter and is the contact for questions regarding deficiencies. |
| Jessica Garcia | Administrator | Administrator of Autumn Lake Healthcare At Cromwell, involved in tours and interviews during inspection. |
| Registered Nurse #1 | Infection Control Nurse | Interviewed regarding infection control practices and unaware of staff using resident nourishment room as break room. |
| Food Service Director #1 | Food Service Director | Interviewed regarding kitchen sanitation and food storage deficiencies. |
| Maintenance Director | Interviewed regarding facility maintenance issues including bathtub water turned off and facility remodeling. | |
| Registered Nurse #1 | Interviewed regarding incident of privacy violation and intravenous therapy education. | |
| Nurse Aide #1 | Involved in privacy violation incident and education regarding intravenous therapy. | |
| Nurse Aide #2 | Involved in privacy violation incident and education regarding intravenous therapy. | |
| Licensed Practical Nurse #1 | Interviewed regarding care of resident with pressure ulcers. | |
| Administrator | Interviewed multiple times regarding facility conditions, remodeling, and infection control. |
Inspection Report
Renewal| Name | Title | Context |
|---|---|---|
| Jessica Garcia | Administrator | Personnel contacted during the inspection. |
| Melissa Dziob | Report submitted by. |
Report
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