Above average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
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 Glen Hill during CMS and state inspections, most recent first.
An open, overflowing garbage can was observed without a lid and placed near the steam table during meal plating, remaining uncovered for about half an hour. The Dietary Manager acknowledged that the garbage can should have been covered and not in proximity to the food service area, in accordance with facility policy requiring sanitary conditions and covered trash containers.
Two residents with cognitive impairment and special dietary needs were left waiting for lunch while another resident at their table was served and ate, resulting in delays of over an hour before the waiting residents received their meals. Staff confirmed that all residents at a table should be served at the same time, and acknowledged the delay was not standard practice.
A resident with severe cognitive impairment and total dependence on staff was found with a fractured thumb of unknown origin. The facility failed to conduct a thorough investigation, as required by policy, by not identifying or interviewing all staff involved in the resident's care or documenting how care was provided during the relevant period.
A resident who was totally dependent on staff did not receive care according to their care plan, which required two staff members for all care, resulting in care being provided by only one staff member. Another resident with respiratory issues did not have interventions for respiratory care or hearing aid maintenance included in their care plan, despite staff acknowledging these omissions. The facility failed to ensure care plans were comprehensive and followed as required.
A resident with overactive bladder, urge incontinence, and CHF was identified as a good candidate for scheduled toileting by multiple screeners and urology consults, but the care plan was not updated to reflect these findings or specialist recommendations. The care plan continued to state the resident could not participate in retraining, and no toileting program was trialed, despite the resident being cognitively intact and requiring substantial assistance with toileting.
A resident with chronic health conditions who required assistance with toileting and preferred female caregivers experienced a significant delay in receiving incontinence care. Despite the care plan reflecting this preference, the resident waited over an hour for a female aide to become available, as the unit was staffed with two male aides and only one female aide. Staff interviews confirmed the delay and the challenges in accommodating resident preferences during the shift.
A resident with overactive bladder, urge incontinence, CHF, and a history of bladder cancer was identified as a good candidate for bladder retraining and scheduled toileting by multiple quarterly screeners and urology consults. Despite being cognitively intact and able to participate, no toileting program was initiated, and the care plan focused only on perineal care and monitoring. The lack of communication and follow-through on screener results and specialist recommendations led to a failure to provide appropriate continence care.
A resident with a history of acute respiratory failure and pneumonia had a standing order for continuous oxygen, but was observed multiple times without oxygen in use and confirmed not receiving it. The care plan lacked respiratory interventions, and staff interviews revealed the resident had been titrated off oxygen without updating the physician's order. Nursing staff and the DNS acknowledged the lapse in ensuring orders were current and accurately implemented.
A resident with a suprapubic urinary catheter was observed multiple times with their foley catheter drainage bag dragging on or touching the floor while attached to their wheelchair, despite facility policy and care plan directives requiring the bag to be kept off the floor. The deficiency was confirmed by the Infection Control Preventionist, who stated that staff are responsible for ensuring proper positioning of the drainage bag.
A resident with severe cognitive impairment and significant physical limitations was left alone on the toilet by a nurse aide who stepped out to retrieve supplies. During the absence, the resident attempted to stand, fell, and sustained injuries to the forehead and knee, despite care plan interventions specifying the resident should not be left alone.
The facility did not make grievance forms accessible to residents, family members, or visitors, and residents were not informed about how to file grievances. During interviews, multiple residents reported being unaware of the grievance process or the location of forms. Observations confirmed the absence of forms on units and that posted policies were not easily visible or instructive for those in wheelchairs. Staff could not provide evidence that the grievance process had been reviewed with residents.
Uncovered Garbage Can Near Food Service Area
Penalty
Summary
During the noon meal plating service, an open industrial garbage can filled to the top with trash was observed without a lid and positioned approximately 15 feet from the steam table where food was being plated. The garbage can remained open for about half an hour during the food service period. The Dietary Manager confirmed that the garbage can should have been covered and not located near the steam table during meal service, and that all kitchen staff are responsible for ensuring trash containers are covered and removed from the serving area. Facility policy requires all food preparation and service areas to be maintained in safe and sanitary conditions, including keeping all trash containers covered in leak-proof containers to prevent cross-contamination.
Failure to Serve Meals Simultaneously Compromises Resident Dignity
Penalty
Summary
Two residents with cognitive impairment and dysphagia were observed waiting for lunch in the lounge area while another resident at their table received their meal significantly earlier. One resident received their meal 1 hour and 50 minutes after the other, while the second resident waited 1 hour and 5 minutes. Both residents were care planned for nutritional risk and required specific dietary accommodations, but were left to watch another resident eat while they waited for their own meals. Staff interviews confirmed that all residents at a table should be served at the same time, and that it was not normal practice for residents to wait such a long period while others ate. The delay in meal service was attributed to the kitchen staff delivering one resident's tray at the time meals were served in the main dining room, while the other two residents' trays were not brought until much later. The nurse aide acknowledged that she should have either provided snacks or obtained the trays for the waiting residents, and reported the delay to the kitchen staff. Facility policy on resident rights emphasized dignity and respect, but a specific dining policy was not provided upon request.
Failure to Conduct Thorough Investigation of Injury of Unknown Origin
Penalty
Summary
A deficiency occurred when the facility failed to conduct a thorough investigation into an injury of unknown origin sustained by a resident with severe cognitive impairment, dementia, involuntary movements, and osteoarthritis. The resident was totally dependent on staff for all activities of daily living and required two-person assistance for bed mobility and transfers, as documented in the care plan. The resident was found with a swollen, red left thumb, which was later diagnosed as a fracture. The incident was reported as a reportable event, and the responsible party and physician were notified. The investigation initiated by the Director of Nursing Services (DNS) was incomplete. Statements from nurse aides and licensed staff did not identify which staff provided care to the resident during the relevant shifts, nor did they provide details about how care was delivered or whether any unusual occurrences took place. The DNS was unable to determine who provided care to the resident on the day prior to the injury, and some staff could not recall their involvement. Additionally, the DNS did not directly interview all relevant staff, and the investigation lacked documentation and clarity regarding the circumstances of the injury. Medical review revealed conflicting diagnoses regarding the nature of the fracture, with initial suggestions of a pathological fracture due to osteoporosis, but later clarification indicated it was not pathological. The facility's abuse policy requires immediate and thorough investigation of injuries of unknown origin, including identification and interviews of all involved individuals, but this was not followed in this case, resulting in an incomplete investigation.
Failure to Follow and Develop Comprehensive Care Plans for Resident Needs
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, dementia, involuntary movements, and osteoarthritis, who was totally dependent on staff for personal hygiene, transfers, toileting, and bed mobility, did not receive care according to their individualized care plan. The care plan and care card specified that two staff members were required to assist with all care, including bed mobility. However, a nursing assistant was observed providing care alone, despite being aware of the two-person assistance requirement. This deviation from the care plan was identified during an investigation into an injury of unknown origin, specifically a fractured left thumb, which may have resulted from care being provided by only one staff member. Another deficiency was identified for a resident with acute respiratory failure, hypoxia, pneumonia, and insomnia. The resident was cognitively intact and required oxygen therapy. The care plan for this resident did not include any interventions to address respiratory care needs, nor did it document any behaviors related to refusal of care. Nursing staff acknowledged that the omission of respiratory interventions was an oversight and that all residents on oxygen should have a care plan addressing this need. Additionally, the same resident was observed using hearing aids, but the care plan did not include interventions for the care or maintenance of the hearing aids. Staff interviews confirmed that the facility is responsible for the care and maintenance of hearing aids and that this should have been included in the care plan. The facility's policy requires comprehensive, person-centered care plans with measurable objectives and timetables, but these requirements were not met for the residents in question.
Failure to Revise Care Plan for Incontinence Management
Penalty
Summary
The facility failed to revise the care plan for a resident with overactive bladder, urge incontinence, and congestive heart failure to reflect the resident's current status and needs. Despite multiple quarterly Bowel and Bladder Program Screeners and urology consults indicating the resident was a good candidate for scheduled toileting (timed voiding), the care plan continued to state the resident was unable to cognitively or physically participate in a retraining program due to impaired mobility. The resident was cognitively intact and required substantial assistance with toileting, but no trial of a toileting program was initiated, and the care plan was not updated to reflect recommendations from the urologist or the results of the screeners. Physician orders and specialist recommendations advised interventions such as timed toileting, limiting nighttime fluids, and avoiding irritants, but these were not incorporated into the care plan. The Director of Nursing Services confirmed that the care plan had not been updated to reflect the resident's candidacy for retraining or the recommendations from the urologist, and that the resident had not been interviewed regarding their wishes for a toileting program. Facility policy required ongoing revision of care plans as resident conditions changed, but this was not followed in this case.
Delay in Incontinence Care Due to Staffing and Resident Preference
Penalty
Summary
A deficiency occurred when a resident with chronic obstructive pulmonary disease and heart disease, who was cognitively intact and required partial to moderate assistance for toileting hygiene, did not receive prompt incontinence care. The resident, who was frequently incontinent of the bladder and had a documented preference for female caregivers, reported having to wait approximately two hours for incontinence care after an episode. Staff interviews confirmed that on a specific evening, the resident requested assistance from a male aide but declined care, expressing a preference for a female aide. The male aide informed the resident that they would need to wait for the female aide to become available, and the resident ultimately waited about one hour to one hour and fifteen minutes before receiving care from a female aide. Further interviews with nursing staff revealed that the unit was staffed with two male aides and one female aide at the time, and the challenge of accommodating multiple female residents' preferences for female caregivers was noted. The LPN on duty was unable to assist due to other responsibilities, and the nursing supervisor was notified of the staffing issue. The care plan for the resident had been updated to reflect the preference for female caregivers, but the resident still experienced a significant delay in receiving incontinence care.
Failure to Implement Scheduled Toileting for Incontinent Resident
Penalty
Summary
The facility failed to implement appropriate interventions to restore or manage bladder and bowel continence for a resident with a history of overactive bladder, urge incontinence, congestive heart failure, and prior bladder cancer. Despite multiple quarterly Bowel and Bladder Program Screeners indicating the resident was a good candidate for retraining or scheduled toileting, and urology consults recommending timed toileting and other interventions, there was no evidence that a toileting program or bladder retraining was trialed. The resident was cognitively intact, required substantial assistance with toileting, and had functional limitations, but the care plan and clinical record did not reflect any attempt to initiate a toileting program as recommended by both the screeners and the urologist. The care plan interventions focused on perineal care, monitoring for infection, and use of disposable briefs, but did not address the recommendations for scheduled toileting or retraining. Physician orders for medications related to bowel and bladder management were present, but the lack of communication and follow-through on the results of the continence screeners and urology recommendations led to a failure in providing appropriate care aimed at restoring or improving continence. The Director of Nursing confirmed that the nursing staff did not inform the care team of the screener results, resulting in missed opportunities to trial a toileting program.
Failure to Maintain Current Physician's Orders for Oxygen Therapy
Penalty
Summary
A deficiency was identified when a resident with diagnoses including acute respiratory failure with hypoxia and pneumonia had a physician's order for continuous oxygen at 1 liter per minute via nasal cannula. Despite this order, multiple observations over several days showed the resident was not receiving oxygen, and the oxygen machine in the room was not in use. The resident confirmed not having received oxygen, and there was no documentation of refusal of treatment in the nurse's notes. The care plan did not include interventions for respiratory care, nor did it document any refusal behaviors. Interviews with staff revealed that the resident had been titrated off oxygen the previous week, but the physician's orders had not been updated to reflect this change. Nursing staff acknowledged responsibility for ensuring orders are accurate and implemented as written. The Director of Nursing Services (DNS) stated that orders should be updated immediately when changes occur but could not explain why the resident was not receiving oxygen as ordered or why the orders were not current. The physician's order was only updated after inquiry to reflect as-needed oxygen administration.
Foley Catheter Drainage Bag Found Touching Floor During Resident Transport
Penalty
Summary
A deficiency was identified when a resident with a suprapubic urinary catheter was observed multiple times with their foley catheter drainage bag attached to the back of their wheelchair, dragging on or touching the floor as the wheelchair was moved. The resident had diagnoses including congenital stricture of the urethra, obstructive and reflex uropathy, and urinary retention, and required moderate assistance for personal hygiene, dressing, and transfers. The resident's care plan and physician orders specified interventions for catheter care, including keeping the drainage bag below the level of the bladder and off the floor, but these were not followed during the observed periods. The facility's policy on urinary catheter care directed that catheter tubing and drainage bags be kept off the floor and handled with clean technique. Despite these requirements, the drainage bag was repeatedly seen touching the floor during several observations. The Infection Control Preventionist confirmed that the drainage bag should not be dragging or touching the floor and that staff responsible for the resident's care should ensure proper positioning of the drainage bag throughout the shift.
Resident Left Unattended in Bathroom Resulting in Fall
Penalty
Summary
A deficiency occurred when a resident with diagnoses including Parkinson's Disease, stroke with right-sided hemiplegia and hemiparesis, and vascular dementia was left unsupervised in the bathroom. The resident was severely cognitively impaired and required maximal assistance with toileting hygiene, personal hygiene, and toilet transfers, as documented in the Minimum Data Set assessment. The resident's care plan specifically identified falls as a concern and included interventions such as not leaving the resident alone and gathering all necessary items before providing care. Despite these interventions, a nurse aide left the resident alone on the toilet to retrieve an incontinent brief from the hallway. During this time, the resident stood up without assistance, fell forward, and sustained injuries including an abrasion and large bump to the forehead and an abrasion to the left knee. The incident was confirmed through clinical record review, staff interviews, and direct observation of the resident's injuries. The facility's policy required staff to implement interventions tailored to the resident's fall risk, which was not followed in this instance.
Failure to Ensure Grievance Process Accessibility and Resident Awareness
Penalty
Summary
The facility failed to ensure that grievance forms were readily available to residents, family members, and visitors, and did not adequately inform residents about the process for filing grievances. During a meeting with twelve residents who regularly attend resident council meetings, all participants stated they were unaware of the grievance process and did not know where the forms were located. Further interviews and observations revealed that no grievance forms were present on the units, and only an empty folder was found in a file drawer. The posted grievance policy was placed high above the State Ombudsman contact form, making it difficult for individuals in wheelchairs to see or read, and the policy did not provide instructions on how to obtain a form or who to contact. Although a social worker stated that the grievance process had been reviewed with residents, no evidence of this could be provided. The facility's policy supported the right to voice grievances but lacked a date and did not ensure accessibility or awareness of the grievance process.
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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 Danbury
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Civita Care Center At Danbury | 0.8 mi | ★★★★★ | 0 | 0 |
| Havencare At Filosa | 1.8 mi | ★★★★★ | 1 | 0 |
| Havencare At Hancock Hall | 1.8 mi | ★★★★★ | 0 | 0 |
| Saint John Paul Ii Center | 2.1 mi | ★★★★★ | 9 | 0 |
| Bethel Health Care Center | 2.6 mi | ★★★★★ | 0 | 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.