Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Autumn Lake Healthcare At Cromwell during CMS and state inspections, most recent first.
The facility was found to have multiple deficiencies in food storage and sanitation practices. Observations included undated and improperly stored food items, unsanitary conditions in the kitchen and storage areas, and a lack of adherence to facility policies on cleanliness and food safety. The Dietary Manager was unaware of some issues, such as dirt and debris from recent air conditioner installation.
The facility did not submit PBJ data for the third quarter of 2023 as required by CMS. The Administrator was aware of this issue and noted that the corporate office was responsible for the submission but failed to do so.
The facility failed to maintain a safe and clean environment across multiple units, with issues such as exposed plumbing, discolored ceiling tiles, broken window blinds, and missing cover plates. The DOM was unaware of how long these problems persisted, indicating a lack of oversight and prompt action.
The facility failed to report resident-to-resident altercations to appropriate agencies. In one case, a resident with dementia was involved in altercations with another resident, resulting in physical contact. The DNS did not notify Adult Protective Services due to a lack of awareness of reporting requirements. In another incident, a cognitively impaired resident touched another resident inappropriately, but the facility did not report it to the state agency, believing there was no malintent. Additionally, a physical altercation over a cellphone occurred between two residents, but Adult Protective Services were not informed.
The facility failed to provide food at a palatable and safe temperature, as reported by several residents who received cold and unappealing meals. A test tray confirmed that the meatloaf and cheesecake were not within acceptable temperature ranges, with issues attributed to a non-functioning pellet plating system and improper storage of desserts.
A resident with hemiplegia and chronic incontinence did not receive timely incontinent care, as required by their care plan. Observations showed a 4-hour gap in care, with dried fecal material found on the resident. Interviews with staff revealed inconsistencies in care timing, and no specific incontinence care policy was provided.
The facility failed to monitor fluid intake for two residents with kidney failure on fluid restrictions, leading to deficiencies in care. One resident with chronic kidney disease had a fluid restriction of 1200 ml per day, but records did not indicate total intake for each 24-hour period. Another resident with end-stage renal disease had intake records not exceeding 480 ml per day without a 24-hour total documented. Staff interviews revealed a lack of process to monitor fluid goals, contributing to the deficiency.
A LTC facility failed to follow physician orders for two residents, leading to deficiencies in medication administration. One resident did not have blood pressure monitored as required before Atenolol administration, resulting in over 340 missed readings. Another resident received incorrect Vitamin D3 dosage and Procrit was administered despite hemoglobin levels exceeding prescribed limits. The facility's medication administration policies were not adequately followed.
A facility failed to maintain proper infection control during wound care for a resident with a stage 4 pressure ulcer, as an LPN did not wear a gown despite EBP requirements. Additionally, the facility's laundry services were found to be unclean, with debris on equipment and improper storage of clean laundry. The facility's policies lacked detailed procedures for maintaining cleanliness in the laundry area.
The facility did not act on concerns raised by the Food Committee, as residents reported that their feedback was not addressed. Specific requests for meal preferences were documented but not implemented, and the Dietary Department lacked a policy for responding to these concerns.
A resident with a new diagnosis of schizoaffective disorder was not referred for a Level II PASRR evaluation as required. Despite the resident's significant change in mental health status, the facility did not submit the necessary referral to the state-designated authority. The social worker, new to the facility, was unaware of the oversight, which was contrary to the facility's policy on coordinating assessments with the PASRR program.
The facility failed to properly date and discard multi-dose vials and expired medications, as observed in several medication storage rooms. Opened vials of Tuberculin PPD and Lidocaine lacked proper dating, and expired medications like Biotin and Omeprazole were not discarded timely. Staff interviews revealed a lack of awareness of the facility's policy on medication dating and disposal, and the facility could not provide a specific policy for multi-use vials.
Deficiencies in Food Storage and Sanitation Practices
Penalty
Summary
The facility failed to maintain proper food storage and sanitation standards in the Dietary Department, as observed during a tour with the Dietary Manager. Several deficiencies were noted, including an accumulation of dust and debris on the threshold of the walk-in refrigerator, and multiple open food items such as hotdogs, Ricotta cheese, pancakes, omelets, French toast, and pork crumble that were not dated with open or expiration dates. Additionally, the Ricotta cheese was found with a black and orange-like substance, and the container for Spanish onions was visibly dirty and uncovered. The ice machine had a heavy accumulation of white and dark substances inside, and dust on the side vents, indicating a lack of regular cleaning. In the Dry Storage room, a bag of dried cranberries was found open to air, and heavy dirt and debris were observed behind the can shelving near the air conditioner. The Dietary Manager was unaware of the dirt and debris, attributing it to recent air conditioner installation. Furthermore, a stained ceiling tile was noted in the third-floor Nourishment Room. The facility's policies on maintaining clean and sanitary food preparation and storage areas were not adhered to, as evidenced by the unsanitary conditions and improper food storage practices observed during the survey.
Failure to Submit PBJ Data for Third Quarter 2023
Penalty
Summary
The facility failed to submit Payroll Based Journal (PBJ) data for the third quarter of 2023, which includes the months of April, May, and June, as required by the Centers for Medicare and Medicaid Services (CMS). During an interview and review of facility documentation on July 25, 2024, the Administrator acknowledged awareness of the failure to submit the PBJ data. The Administrator indicated that the responsibility for submitting the PBJ data to CMS lay with the facility's corporate office, which did not fulfill this obligation.
Environmental Deficiencies Across Multiple Units
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for residents across multiple units, as observed during surveys conducted on two separate days. On the Elm Unit, several issues were identified, including exposed plumbing and wall studs due to missing drywall and tile, discolored ceiling tiles with a black substance, and peeling paint with holes in the drywall. The Director of Maintenance (DOM) was unable to specify how long these issues had persisted, indicating a lack of awareness and oversight. On the Maple Unit, similar deficiencies were noted, such as a fallen radiator faceplate, broken window blinds, a permanently locked bathroom door handle, and discolored ceiling tiles. The DOM again expressed uncertainty regarding the duration of these problems, suggesting that they were not promptly identified or addressed during environmental rounds. Additionally, the Oak Unit exhibited issues like stained toilet bowls, exposed sheetrock, missing cover plates with exposed wires, and dusty bathroom vents. The DOM acknowledged that some of these issues were missed during previous inspections. The Hickory Unit also had notable deficiencies, including holes stuffed with paper towels and a missing faceplate cover above a resident's bed. The DOM confirmed that environmental rounds are conducted quarterly, and maintenance logs are reviewed routinely. However, the persistence of these issues across multiple units indicates a systemic failure to ensure a safe and sanitary environment for residents, as the DOM admitted that the identified concerns were unacceptable.
Failure to Report Resident-to-Resident Altercations
Penalty
Summary
The facility failed to report allegations of mistreatment involving resident-to-resident altercations to the appropriate agencies, including Adult Protective Services and the state survey agency. In one instance, a resident with dementia and hallucinations, identified as Resident #20, was involved in two separate altercations with another resident, Resident #153, who also had dementia and hallucinations. During these incidents, Resident #20 slapped Resident #153, and in another instance, hit Resident #153 in the face. Although the police and responsible parties were notified, Adult Protective Services were not informed, as the Director of Nursing Services (DNS) was unaware of the requirement to report such incidents. In another case, Resident #140, who was severely cognitively impaired, was observed touching another resident, Resident #80, on the chest over clothing. Despite the incident being reported to the DNS and an internal investigation being conducted, the facility did not report the incident to the state survey agency. The DNS and other staff believed that due to the cognitive impairments of both residents, there was no malintent, and thus, the incident was not reportable. Additionally, an altercation occurred between Resident #20 and Resident #668, where Resident #668 attempted to take Resident #20's cellphone, leading to a physical confrontation. Both residents sustained minor injuries, and while the police and responsible parties were notified, Adult Protective Services were not informed. The DNS admitted to being unaware of the state guidelines requiring notification of Adult Protective Services in such cases.
Food Temperature and Palatability Deficiency
Penalty
Summary
The facility failed to ensure that food served to residents was palatable, attractive, and at a safe and appetizing temperature. Multiple residents reported dissatisfaction with the food, citing issues such as receiving cold meals, unappealing presentation, and a lack of awareness about meal options. Specific complaints included cold food, mushy vegetables, and a general lack of appeal in the meals provided. These observations were corroborated by interviews with several residents who expressed their dissatisfaction with the quality and temperature of the food served. A test tray conducted with the Dietary Manager revealed that the food temperatures were not within the acceptable range. The meatloaf's internal temperature was significantly below the palatable temperature of 135 degrees Fahrenheit, and the cheesecake was served at a temperature much higher than the recommended 38 to 40 degrees Fahrenheit. The Dietary Manager identified that the cheesecake was stored on an open metal cart for an extended period, contributing to its high temperature, while the low temperature of the meatloaf was attributed to a non-functioning pellet plating system.
Failure to Provide Timely Incontinent Care
Penalty
Summary
The facility failed to provide timely incontinent care to Resident #103, who was diagnosed with hemiplegia and hemiparesis following a stroke and was always incontinent of bowel and bladder. The resident was totally dependent on staff for bed mobility and toileting hygiene. The care plan required that the resident receive incontinent care every 2 hours and as needed. However, observations on 7/24/24 revealed that the resident had not received care for approximately 4 hours, as dried fecal material was found on the resident's buttocks, indicating a lack of timely care. Interviews with nursing assistants and the LPN revealed inconsistencies in the timing of care provided to the resident. NA #2 claimed to have provided care at 7:45 AM and checked the resident at 11:00 AM, but the surveyor did not observe NA #2 entering the room at that time. The LPN expected care to be provided every 2 hours, but the resident was not checked until 11:39 AM. The Director of Nursing Services stated that care is given 4 times a shift and as needed, but no specific policy for incontinence care was provided upon request.
Failure to Monitor Fluid Intake for Residents on Fluid Restrictions
Penalty
Summary
The facility failed to implement a systematic approach to assess daily fluid intake for residents with kidney failure on fluid restrictions, leading to deficiencies in care for two residents. Resident #94, diagnosed with chronic kidney disease Stage 4 and diabetes, had a physician's order for a fluid restriction of 1200 ml per day. However, the Medication Administration Record (MAR) did not indicate a total fluid intake for each 24-hour period, and the clinical record lacked calculations of total fluid intake from 7/14/24 through 7/20/24. Interviews revealed that the facility did not have a mechanism to total fluid intake every 24 hours, and there was no designated staff to monitor if the fluid goal was met or exceeded. Resident #152, with diagnoses including end-stage renal disease and congestive heart failure, was also on a fluid restriction of 1200 ml per day. Observations noted dry mucous membranes, and intake and output records showed documentation that did not exceed 480 ml per day without a 24-hour total documented. The Director of Nursing Services (DNS) acknowledged that the intake and output record flowsheets were not part of the official clinical record and that a total intake for 24 hours was not documented. Interviews with staff indicated a lack of process to identify when a resident did not meet their fluid goal for consecutive days. The facility's policy directed staff to record fluid intake and total amounts at the end of each shift, but this was not consistently followed. The clinical record for Resident #152 failed to reflect documentation of total fluid intake meeting the fluid restriction, with 14 days of documented amounts not totaling over 800 ml for 24 hours. There was no corresponding nursing staff documentation or assessments to indicate the resident's hydration status when fluid intake did not meet 800 ml. The facility lacked a process to tally 24-hour totals and identify deviations from fluid goals or restrictions, contributing to the deficiency.
Medication Administration Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to physician orders for two residents, leading to deficiencies in medication administration. For Resident #25, who had diagnoses including hypertension and atrial fibrillation, the physician ordered Atenolol to be administered with specific parameters: holding the medication if the systolic blood pressure was less than 100 or the heart rate was less than 60 beats per minute. However, the facility did not consistently take the resident's blood pressure before administering the medication, resulting in over 340 missed blood pressure readings. Interviews with LPNs revealed that the electronic system did not prompt for a blood pressure reading, contributing to the oversight. For Resident #107, who had conditions such as anemia and chronic myeloid leukemia, there were multiple issues with medication orders. A pharmacy consultant recommended a change in Vitamin D dosage, which was misinterpreted by the APRN, leading to the resident receiving Vitamin D3 50,000 units twice a month instead of once. Additionally, the resident was to receive Procrit with specific parameters to hold the medication if hemoglobin levels were above 10. Despite this, Procrit was administered when the hemoglobin was 11.1 and 10.1 on separate occasions, contrary to the physician's orders. The APRN and LPNs involved were unaware of the errors in medication administration. The facility's policies on administering medications and following physician orders were not adequately followed, as evidenced by the lack of pre-administration assessments and incorrect medication orders. The absence of a facility policy for physician orders further compounded the issue, leading to the administration of unnecessary medications and failure to adhere to prescribed parameters.
Infection Control and Laundry Cleanliness Deficiencies
Penalty
Summary
The facility failed to maintain proper infection control techniques for Enhanced Barrier Precautions (EBP) during wound care for a resident with subacute osteomyelitis and a stage 4 pressure ulcer. The resident was cognitively intact and dependent on staff for various activities. Despite the presence of EBP signage and a physician's order requiring EBP, an LPN performed wound care without wearing a gown, as required. The LPN was unaware of the EBP requirement for the resident and only realized the oversight after reviewing the Medication Administration Record and Treatment Administration Record. The Infection Preventionist confirmed that the nurse should have worn a gown and gloves during wound care, and noted that the facility was still working on staff education regarding EBP. In the facility's laundry services, the environment was not maintained in a clean state, as observed in the laundry room. There was a moderate buildup of debris on washers, dryers, and other surfaces, and a dark gray substance on the ceiling fan and filters. The Regional Environmental Services Manager, who visits the facility weekly, acknowledged the need for thorough cleaning, as similar conditions had been observed previously. The Environmental Services Director also noted issues with open windows allowing substances to re-enter the dryer room, where clean laundry was stored uncovered. Despite the cleaning schedule being signed off as completed, the observed conditions indicated otherwise. The facility's laundry policy did not include specific procedures for clean laundry operations, such as drying, folding, storage, or cleaning of the laundry areas. This lack of detailed policy contributed to the deficiencies observed in maintaining a clean environment for laundry processing. The facility's failure to ensure proper infection control and environmental cleanliness in the laundry area highlights significant lapses in adherence to established protocols and procedures.
Failure to Address Food Committee Concerns
Penalty
Summary
The facility failed to address concerns raised by the Food Committee, as evidenced by interviews with residents and staff, and a review of committee minutes. During a Resident Council meeting, two residents reported that despite providing feedback during monthly Food Committee meetings, no corrective actions were taken. Specific requests from residents, such as smaller portions, no bread, dislike of pork, and preferences for egg servings, were documented in the committee minutes but were not acted upon by the Dietary Department. The Regional Dietary Manager's review of food tickets from January to July 2024 confirmed that no notes were added to reflect these requests. Additionally, the Dietary Manager acknowledged the absence of a policy for responding to Food Committee concerns.
Failure to Refer Resident for Level II PASRR Evaluation
Penalty
Summary
The facility failed to refer a resident for a Level II Preadmission Screening and Resident Review (PASRR) evaluation and determination after a new psychiatric diagnosis was identified. The resident, who was initially screened with a PASRR Level I on March 4, 2020, was diagnosed with schizoaffective disorder in September 2020. Despite this significant change in the resident's mental health status, the facility did not submit a referral for a Level II PASRR evaluation to the appropriate state-designated authority. The resident's medical history included dementia, congestive heart failure, and a new diagnosis of schizoaffective disorder. Psychological service notes from September 2020 and May 2022 confirmed the presence of a psychotic disorder and schizoaffective disorder, respectively. The resident's care plan, updated in January 2024, acknowledged the psychosocial wellbeing problem related to the schizoaffective disorder. However, the social worker, who began working at the facility in 2023, was unaware of why the Level II PASRR had not been completed and admitted that it might have been overlooked. The facility's policy mandates coordination with the PASRR program to ensure appropriate care for residents with mental diseases, but this was not adhered to in this case.
Medication Storage Deficiencies
Penalty
Summary
The facility failed to adhere to its medication storage policies, resulting in several deficiencies related to the handling of multi-dose vials and expired medications. During a review of the medication storage rooms, it was observed that a vial of Tuberculin PPD on the Maple Unit was opened and dated 2/28/24, well beyond the 30-day usage period. Additionally, a vial of Lidocaine on the same unit was opened but lacked an opening date. On the Oak Unit, a bottle of Biotin with an expiration date of 1/2024 was found, and two bottles of Omeprazole suspension were noted to be expired, with one opened and dated 5/20/24 and the other sealed but expired on 7/18/24. Similarly, on the Elm Unit, a vial of Tuberculin PPD was opened and dated 3/13/24, exceeding the recommended usage period. Interviews with facility staff revealed a lack of awareness and adherence to the facility's policy regarding the dating and disposal of multi-dose vials. The ADNS and Infection Control Nurse confirmed that the policy required dating upon opening and discarding after 30 days, but an LPN was unaware of this policy. Pharmacists highlighted the importance of adhering to expiration dates to prevent infection risks. Despite requests, the facility could not provide a specific policy for multi-use medication vials, indicating a gap in documentation and staff training.
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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 Cromwell
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pilgrim Manor | 0.6 mi | ★★★★★ | 0 | 0 |
| Portland Care & Rehab Centre, Inc | 1.6 mi | ★★★★★ | 19 | 0 |
| Water's Edge Center For Health & Rehab | 3.1 mi | ★★★★★ | 15 | 0 |
| Apple Rehab Cromwell | 3.4 mi | ★★★★★ | 20 | 0 |
| Wadsworth Glen Health Care And Rehabilitation Cent | 3.6 mi | ★★★★★ | 13 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.