Report
TheVardellReport
Autumn Lake Healthcare at Windsor
Skilled nursing facility and nursing facility
581 Poquonock Ave
Windsor, CT 06095
Report
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The Vardell Report.Autumn Lake Healthcare at Windsor
The deeper story, beautifully organized. Available records, historical context, and questions worth asking.
- Provider Category
- Nursing home
- Location
- Windsor, CT
- Record Period
- 2021–2026
- Source Documents
- 7
This report is free. Vardell does not certify, grade or endorse; it shows what the record documents.
The Essentials
Summary
Across 5 inspections from December 2021 to April 2026, state surveyors documented 51 findings at Autumn Lake Healthcare at Windsor; 51 have a recorded correction; CMS lists 2 enforcement actions in the window.
- Inspections
- 5
- 2021–2026, complaint and standard
- Findings
- 51
- Deficiencies cited by state inspectors
- Corrected
- 51
- Of 51 findings, with a recorded correction date
- Penalties
- 2
- 2 fines; payment not published
Findings by Year
- Findings
- Of which, actual harm (level G or above)
* Partial year, through October 1, 2026.
| Year | Inspections | Findings | Of which, actual harm (level G or above) |
|---|---|---|---|
| 2021 | 1 | 5 | 0 |
| 2022 | 0 | 0 | 0 |
| 2023 | 0 | 0 | 0 |
| 2024 | 1 | 14 | 0 |
| 2025 | 1 | 1 | 0 |
| 2026 | 2 | 31 | 1 |
What the Record Shows
- 51 of 51 findings have a recorded correction date.
- CMS lists 2 enforcement actions in the window: 2 fines totaling $130,836, their payment not published.
- 3 visits in this window included a complaint investigation. CMS publishes what a complaint investigation cited, not what the complaint alleged.
- The latest standard inspection, March 11, 2026, recorded 30 findings (most serious: Level G).
What to Ask About
- Accurate Assessments, Cited in Three Inspections
- Help With Daily Living, Cited in Three Inspections
- Telling Families About Changes, Cited in Two Inspections
- Protection From Abuse and Neglect, Cited in Two Inspections
- Care Plan Timing and Review, Cited in Two Inspections
- Pharmacy Services, Cited in Two Inspections
- Citation F790, Cited in Two Inspections
- Kitchen and Food Safety, Cited in Two Inspections
- Medical Records, Cited in Two Inspections
- Infection Control, Cited in Two Inspections
Report at a Glance
- Facility
- Autumn Lake Healthcare at Windsor
- Address
- 581 Poquonock Ave, Windsor, CT 06095
- CMS Certification Number
- 075011
- Provider Type
- Skilled nursing facility and nursing facility
- Certified Beds
- 108
- Ownership
- For profit - Corporation
- Record Window
- December 7, 2021 to October 1, 2026
Chronology
Inspection History
Every inspection in the record window, newest first. A finding is a deficiency an inspector cited. CMS publishes what a complaint investigation cited, not what the complaint alleged.
- 2026
Complaint investigation
1 finding
- F745Provide medically-related social services to help each resident achieve the highest possible quality of life.Level DNo actual harm, potential for moreCorrected May 15, 2026
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2026
Standard health inspection
30 findings
- F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Level GActual harmCorrected Apr 20, 2026
- F851Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.Level FNo actual harm, potential for moreCorrected Apr 20, 2026
- F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level ENo actual harm, potential for moreCorrected Apr 20, 2026
- F726Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.Level ENo actual harm, potential for moreCorrected Apr 20, 2026
- F730Observe each nurse aide's job performance and give regular training.Level ENo actual harm, potential for moreCorrected Apr 20, 2026
- F759Ensure medication error rates are not 5 percent or greater.Level ENo actual harm, potential for moreCorrected Apr 20, 2026
- F761Ensure 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.Level ENo actual harm, potential for moreCorrected Apr 20, 2026
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level ENo actual harm, potential for moreCorrected Apr 20, 2026
- F881Implement a program that monitors antibiotic use.Level ENo actual harm, potential for moreCorrected Apr 20, 2026
- F882Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.Level ENo actual harm, potential for moreCorrected Apr 20, 2026
- F947Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.Level ENo actual harm, potential for moreCorrected Apr 20, 2026
- F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Level DNo actual harm, potential for moreCorrected Apr 20, 2026
- F559Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.Level DNo actual harm, potential for moreCorrected Apr 20, 2026
- F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Level DNo actual harm, potential for moreCorrected Apr 20, 2026
- F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level DNo actual harm, potential for moreCorrected Apr 20, 2026
- F610Respond appropriately to all alleged violations.Level DNo actual harm, potential for moreCorrected Apr 20, 2026
- F628Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.Level DNo actual harm, potential for moreCorrected Apr 20, 2026
- F644Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.Level DNo actual harm, potential for moreCorrected Apr 20, 2026
- F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Level DNo actual harm, potential for moreCorrected Apr 20, 2026
- F658Ensure services provided by the nursing facility meet professional standards of quality.Level DNo actual harm, potential for moreCorrected Apr 20, 2026
- F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Apr 20, 2026
- F692Provide enough food/fluids to maintain a resident's health.Level DNo actual harm, potential for moreCorrected Apr 20, 2026
- F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Level DNo actual harm, potential for moreCorrected Apr 20, 2026
- F790Provide routine and 24-hour emergency dental care for each resident.Level DNo actual harm, potential for moreCorrected Apr 20, 2026
- F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreCorrected Apr 20, 2026
- F883Develop and implement policies and procedures for flu and pneumonia vaccinations.Level DNo actual harm, potential for moreCorrected Apr 20, 2026
- F887Educate 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.Level DNo actual harm, potential for moreCorrected Apr 20, 2026
- F582Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.Level BPotential for minimal harmCorrected Apr 20, 2026
- F641Ensure each resident receives an accurate assessment.Level BPotential for minimal harmCorrected Apr 20, 2026
- F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Level BPotential for minimal harmCorrected Apr 20, 2026
Enforcement Action
Civil money penalty, $111,404 imposed March 11, 2026. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of March 11, 2026, the nearest before the penalty date.
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2025
Complaint investigation
1 finding
- F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Level DNo actual harm, potential for moreCorrected Jun 2, 2025
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2024
Standard health inspection
14 findings
The same visit included a complaint investigation.
- F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Level ENo actual harm, potential for moreCorrected Mar 15, 2024
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level ENo actual harm, potential for moreCorrected Mar 15, 2024
- F850Hire a qualified full-time social worker in a facility with more than 120 beds.Level ENo actual harm, potential for moreCorrected Mar 15, 2024
- F880Provide and implement an infection prevention and control program.Level ENo actual harm, potential for moreCorrected May 7, 2024
- F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Level DNo actual harm, potential for moreCorrected Mar 15, 2024
- F660Plan the resident's discharge to meet the resident's goals and needs.Level DNo actual harm, potential for moreCorrected May 7, 2024
- F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level DNo actual harm, potential for moreCorrected Mar 15, 2024
- F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level DNo actual harm, potential for moreCorrected Mar 15, 2024
- F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Level DNo actual harm, potential for moreCorrected May 7, 2024
- F698Provide safe, appropriate dialysis care/services for a resident who requires such services.Level DNo actual harm, potential for moreCorrected Mar 15, 2024
- F790Provide routine and 24-hour emergency dental care for each resident.Level DNo actual harm, potential for moreCorrected Mar 15, 2024
- F806Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.Level DNo actual harm, potential for moreCorrected Mar 15, 2024
- F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Level DNo actual harm, potential for moreCorrected Mar 15, 2024
- F641Ensure each resident receives an accurate assessment.Level BPotential for minimal harmCorrected Mar 15, 2024
Enforcement Action
Civil money penalty, $19,432 imposed March 12, 2024. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of March 12, 2024, the nearest before the penalty date.
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2021
Standard health inspection
5 findings
- F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Level ENo actual harm, potential for moreCorrected Feb 17, 2022
- F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level DNo actual harm, potential for moreCorrected Feb 17, 2022
- F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level DNo actual harm, potential for moreCorrected Feb 17, 2022
- F695Provide safe and appropriate respiratory care for a resident when needed.Level DNo actual harm, potential for moreCorrected Feb 17, 2022
- F641Ensure each resident receives an accurate assessment.Level BPotential for minimal harmCorrected Feb 17, 2022
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Severity levels follow the CMS scope and severity grid. A–C: potential for minimal harm. D–F: no actual harm, potential for more than minimal harm. G–I: actual harm. J–L: immediate jeopardy.
Context
Patterns Worth Examining
A repeated citation can merit attention, but context and corrective action must be reviewed before drawing a conclusion.
- 1
Accurate Assessments, Cited in Three Inspections
Inspectors cited F641 in December 2021, March 2024 and March 2026. This citation covers whether each resident’s assessment correctly records their condition. None rose above level B (potential for minimal harm). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
2124252626F641 across all 5 inspections, oldest to newest - 2
Help With Daily Living, Cited in Three Inspections
Inspectors cited F677 in December 2021, March 2024 and March 2026. This citation covers help with bathing, dressing, eating and toileting for residents who cannot manage alone. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
2124252626F677 across all 5 inspections, oldest to newest - 3
Telling Families About Changes, Cited in Two Inspections
Inspectors cited F580 in March 2024 and March 2026. This citation covers whether the resident, their doctor and a family member are told promptly about an injury, a decline or another significant change. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
2124252626F580 across all 5 inspections, oldest to newest - 4
Protection From Abuse and Neglect, Cited in Two Inspections
Inspectors cited F600 in June 2025 and March 2026. This citation covers whether residents are protected from abuse and neglect by anyone. The most serious of these was recorded at level G (actual harm). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
2124252626F600 across all 5 inspections, oldest to newest - 5
Care Plan Timing and Review, Cited in Two Inspections
Inspectors cited F657 in March 2024 and March 2026. This citation covers whether care plans are written on time and revised by a team that includes the resident’s caregivers. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
2124252626F657 across all 5 inspections, oldest to newest - 6
Pharmacy Services, Cited in Two Inspections
Inspectors cited F755 in December 2021 and March 2026. This citation covers pharmacy services and the licensed pharmacist who oversees them. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
2124252626F755 across all 5 inspections, oldest to newest - 7
Citation F790, Cited in Two Inspections
Inspectors cited F790 in March 2024 and March 2026. The agency describes it this way: Provide routine and 24-hour emergency dental care for each resident. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
2124252626F790 across all 5 inspections, oldest to newest - 8
Kitchen and Food Safety, Cited in Two Inspections
Inspectors cited F812 in March 2024 and March 2026. This citation covers how food is stored, prepared and served. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
2124252626F812 across all 5 inspections, oldest to newest - 9
Medical Records, Cited in Two Inspections
Inspectors cited F842 in March 2024 and March 2026. This citation covers whether resident records are complete, accurate and kept confidential. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
2124252626F842 across all 5 inspections, oldest to newest - 10
Infection Control, Cited in Two Inspections
Inspectors cited F880 in March 2024 and March 2026. This citation covers hand hygiene, isolation practice and the home’s infection-prevention program. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
2124252626F880 across all 5 inspections, oldest to newest
For Your Next Visit
Questions to Ask on Your Visit
Bring these to the tour. Each one comes from something in the record; the reason is under the question.
- 01
Who completes resident assessments, and how are they checked for accuracy?
Accurate Assessments: cited in three inspections, most seriously at level B.
- 02
How long do residents usually wait for help with bathing, dressing or the bathroom, and how is that tracked?
Help With Daily Living: cited in three inspections, most seriously at level E.
- 03
How quickly will we hear about a fall, an injury or a change in condition, and from whom?
Telling Families About Changes: cited in two inspections, most seriously at level E.
- 04
What happened after the abuse or neglect citation, and what changed in training or supervision?
Protection From Abuse and Neglect: cited in two inspections, most seriously at level G.
- 05
How often are care plans revised, and who takes part in the review?
Care Plan Timing and Review: cited in two inspections, most seriously at level D.
- 06
How often does the consultant pharmacist review each resident’s medications?
Pharmacy Services: cited in two inspections, most seriously at level E.
- 07
What changed after F790 was cited, and how do you check it now?
Citation F790: cited in two inspections, most seriously at level D.
- 08
May we see the kitchen, and what do your own sanitation checks look like week to week?
Kitchen and Food Safety: cited in two inspections, most seriously at level E.
- 09
How can a family request a resident’s records, and how are they kept accurate?
Medical Records: cited in two inspections, most seriously at level D.
- 10
Who leads infection control here, and how often are hand-hygiene and isolation practices audited?
Infection Control: cited in two inspections, most seriously at level E.
- 11
How many nurses and aides are on each shift, including nights and weekends, for the unit we are considering?
No staffing citation appears in this window. Staffing levels are published separately by CMS and are worth asking about directly.
- 12
What led to the 2026 fine, and has it been paid?
A $111,404 civil money penalty was imposed March 11, 2026. CMS publishes the fine, not whether it has been paid. The record holds two enforcement actions in the window.
The Evidence
Sources and Coverage
Inspection results and penalties are published by the Centers for Medicare & Medicaid Services from surveys conducted by the Connecticut state survey agency.
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Connecticut state survey agency
Inspection Dec 7, 2021 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Connecticut state survey agency
Inspection Mar 12, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Connecticut state survey agency
Inspection Jun 9, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Connecticut state survey agency
Inspection Mar 11, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Connecticut state survey agency
Inspection Apr 14, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Penalties, Provider Data CatalogView Dataset ↗
Centers for Medicare & Medicaid Services
Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Provider Information, Provider Data CatalogView Dataset ↗
Centers for Medicare & Medicaid Services · 075011
Published Oct 1, 2026 · Retrieved Nov 1, 2026
Coverage
Record windowDecember 7, 2021 – October 1, 2026
- CMS publishes about three inspection cycles; inspections before December 2021 are not in this release.
- CMS refreshes these files monthly, after statements of deficiencies are processed, so an inspection from the last two months may not appear yet.
What This Report Cannot Tell You
- Complaints not investigated onsite
- Allegations screened out by the state before an onsite visit are not published.
- Complaint allegations
- CMS publishes the deficiencies a complaint survey cited, not the allegation itself.
- Facility-reported incidents
- Self-reported incidents appear only if they led to an inspection.
- Follow-up visits
- CMS's files list standard, complaint and infection control surveys, not revisits; a correction date is the one CMS records.
- Fire safety inspections
- Published by CMS separately and not included in this record yet.
- Staffing levels and ownership history
- Published by CMS separately and not included in this record.
- Whether fines were paid
- CMS publishes the fines imposed, not whether or when they were paid.
Historical coverage varies by agency and location. Missing records do not mean that no complaint or violation occurred.
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