Cycle 1
Health 2025-11-14 · Fire 2025-11-14
7 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Woodbridge, CT
Autumn Lake Healthcare At The Willows
4-star overall rating with 4-star inspections with 7 recent health deficiencies
225 Amity Rd, Woodbridge, CT
(203) 387-0076
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
90
Certified beds
Average residents
85
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Autumn Lake Healthcare
Operator or chain grouping
Approved since
1990-02-26
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
60 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.72
Registered nurse staffing · state 0.70 · national 0.68
LPN hours / resident day
0.92
Licensed practical nurse staffing · state 0.84 · national 0.87
Aide hours / resident day
1.96
Nurse aide staffing · state 2.28 · national 2.35
Total nurse hours
3.59
All reported nurse hours · state 3.83 · national 3.89
Licensed hours
1.63
RN + LPN hours · state 1.54 · national 1.54
Weekend hours
3.25
Weekend nurse staffing · state 3.41 · national 3.43
Weekend RN hours
0.52
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.65
CMS adjusted RN staffing hours
Adjusted total hours
3.26
CMS adjusted total nurse staffing hours
Case-mix index
1.51
Higher values indicate more complex resident acuity
RN turnover
31%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
27%
Annual nurse turnover · state 38% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,309
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
50.31
Composite VBP score used to determine payment impact.
Payment multiplier
1.0044
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
6.73
Baseline 21.79% · Performance 18.35% · Measure score 6.73 · Achievement 6.65 · Improvement 6.73
Healthcare-associated infections
5.32
Baseline 7.67% · Performance 6.25% · Measure score 5.32 · Achievement 5.32 · Improvement 4.83
Total nurse turnover
7.23
Baseline 34.67% · Performance 34.15% · Measure score 7.23 · Achievement 7.23 · Improvement 0.03
Adjusted total nurse staffing
0.85
Baseline 3.87 hours · Performance 3.32 hours · Measure score 0.85 · Achievement 0.85 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.24% |
10.72%
0.5 pts better
|
No Different than the National Rate · Eligible stays 177 · Observed rate 10.73% · Lower 95% interval 7.45% |
| Discharge to community | 67.18% |
50.57%
16.6 pts better
|
Better than the National Rate · Eligible stays 165 · Observed rate 56.36% · Lower 95% interval 58.6% |
| Medicare spending per beneficiary | 1.08 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 98.6% |
95.27%
3.3 pts better
|
Numerator 141 · Denominator 143 |
| Falls with major injury | 0.7% |
0.77%
0.1 pts better
|
Numerator 1 · Denominator 143 |
| Discharge self-care score | 42.72% |
53.69%
11 pts worse
|
Numerator 44 · Denominator 103 |
| Discharge mobility score | 40.78% |
50.94%
10.2 pts worse
|
Numerator 42 · Denominator 103 |
| Pressure ulcers or injuries, new or worsened | 1.4% |
2.29%
0.9 pts better
|
Numerator 2 · Denominator 143 · Adjusted rate 1.51% |
| Healthcare-associated infections requiring hospitalization | 6.24% |
7.12%
0.9 pts better
|
No Different than the National Rate · Eligible stays 103 · Observed rate 4.85% · Lower 95% interval 3.93% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 154 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 55.34% |
56.45%
1.1 pts worse
|
Numerator 57 · Denominator 103 |
| Transfer of health information to provider | 97.83% |
95.95%
1.9 pts better
|
Numerator 45 · Denominator 46 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 73 · Denominator 73 |
| Resident COVID-19 vaccinations up to date | 66.22% |
25.2%
41 pts better
|
Numerator 49 · Denominator 74 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.6 |
2.1
1.5 pts worse
|
1.9
1.7 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.6 · Observed 3.9 · Expected 2.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.6 |
1.5
0.1 pts worse
|
1.8
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.5 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.6% |
87.5%
10.1 pts better
|
93.4%
4.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 93.7% · Q2 98.4% · Q3 98.5% · Q4 100.0% · 4Q avg 97.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 91.3% |
93.5%
2.2 pts worse
|
95.5%
4.2 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 91.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.4% |
3.4%
1 pts better
|
3.3%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 3.3% · Q3 3.0% · Q4 1.5% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 56.2% |
17.1%
39.1 pts worse
|
11.4%
44.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 35.8% · Q2 55.8% · Q3 82.1% · Q4 50.0% · 4Q avg 56.2% |
| Percentage of long-stay residents who lose too much weight | 13.0% |
6.4%
6.6 pts worse
|
5.4%
7.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.6% · Q2 16.1% · Q3 14.3% · Q4 8.5% · 4Q avg 13.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 7.2% |
17.3%
10.1 pts better
|
19.6%
12.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.8% · Q2 8.5% · Q3 6.7% · Q4 6.8% · 4Q avg 7.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 21.5% |
19.4%
2.1 pts worse
|
16.7%
4.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.8% · Q2 22.9% · Q3 19.6% · Q4 13.3% · 4Q avg 21.5% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 14.6% |
18.1%
3.5 pts better
|
16.3%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 28.3% · Q4 11.9% · 4Q avg 14.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 19.5% |
18.4%
1.1 pts worse
|
14.9%
4.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 40.0% · Q2 16.1% · Q3 12.3% · Q4 10.3% · 4Q avg 19.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.4% |
0.9%
0.5 pts better
|
1.0%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.7% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.0% |
1.7%
0.3 pts worse
|
1.7%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 1.7% · Q3 3.2% · Q4 1.5% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 22.6% |
24.8%
2.2 pts better
|
19.8%
2.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.4% · Q2 30.3% · Q3 11.8% · Q4 27.6% · 4Q avg 22.6% |
| Percentage of long-stay residents with pressure ulcers | 7.1% |
4.4%
2.7 pts worse
|
5.1%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.2% · Q2 8.8% · Q3 4.4% · Q4 6.2% · 4Q avg 7.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.8% |
70.5%
27.3 pts better
|
81.7%
16.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 95.6% · Q2 98.1% · Q3 99.3% · Q4 98.6% · 4Q avg 97.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 15.4% |
11.1%
4.3 pts worse
|
12.0%
3.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 15.4% · Observed 14.4% · Expected 10.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.4% |
1.5%
1.1 pts better
|
1.6%
1.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.8% · Q2 0.9% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 94.4% |
69.7%
24.7 pts better
|
79.7%
14.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 94.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 21.5% |
25.0%
3.5 pts better
|
23.9%
2.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 21.5% · Observed 18.4% · Expected 20.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-01-10 · Fire 2024-01-10
15 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2021-09-22 · Fire 2021-09-22
3 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-01-10
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-02-05
E · Potential for more than minimal harm
2024-01-10
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-02-05
D · Potential for more than minimal harm
2024-01-10
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-02-05
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-11-14
F761 · Pharmacy Service Deficiencies
Health
Ensure 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.
Corrected 2025-11-18
E · Potential for more than minimal harm
2025-11-14
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2025-11-18
D · Potential for more than minimal harm
2025-11-14
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-11-18
D · Potential for more than minimal harm
2025-11-14
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2025-11-18
D · Potential for more than minimal harm
2025-11-14
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2025-11-18
D · Potential for more than minimal harm
2025-11-14
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2025-11-18
D · Potential for more than minimal harm
2025-11-14
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-11-18
D · Potential for more than minimal harm
2024-08-13
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-09-23
D · Potential for more than minimal harm
2024-08-13
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-09-23
D · Potential for more than minimal harm
2024-04-12
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-05-06
D · Potential for more than minimal harm
2024-04-12
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-05-06
F · Potential for more than minimal harm
2024-01-10
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-02-24
E · Potential for more than minimal harm
2024-01-10
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-02-24
D · Potential for more than minimal harm
2024-01-10
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-02-24
D · Potential for more than minimal harm
2024-01-10
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-02-24
D · Potential for more than minimal harm
2024-01-10
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-02-24
D · Potential for more than minimal harm
2024-01-10
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2024-02-24
D · Potential for more than minimal harm
2024-01-10
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-02-24
D · Potential for more than minimal harm
2024-01-10
F761 · Pharmacy Service Deficiencies
Health
Ensure 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.
Corrected 2024-02-24
D · Potential for more than minimal harm
2024-01-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-02-24
B · Minimal harm
2024-01-10
F568 · Resident Rights Deficiencies
Health
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
Corrected 2024-02-24
B · Minimal harm
2024-01-10
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2024-02-24
D · Potential for more than minimal harm
2021-09-22
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2021-10-08
D · Potential for more than minimal harm
2021-09-22
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2021-10-08
D · Potential for more than minimal harm
2021-09-22
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2021-10-08
Penalties and ownership
What sits behind the stars
Ownership
Aut Ct7 Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Kc Derby Ct Al Opco Jv LLC
5% Or Greater Direct Ownership Interest · Organization
Mongillo, Peter
W-2 Managing Employee · Individual
Perera, Channa
Contracted Managing Employee · Individual
Schwartz, Mark
Operational/Managerial Control · Individual
Stern, Samuel
Corporate Officer · Individual
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#2
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4-star overall rating with 3-star inspections with 10 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
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1-star overall rating with 1-star inspections with Special Focus status with $250,575 in total fines with 39 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
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