Safety Report: Autumn Lake Healthcare At Windsor
How to read this report. Every nursing home receives some citations. One citation does not mean a facility is unsafe. Look at how serious the findings were, whether the same problems keep coming back, and whether things are getting better or worse. Learn how inspections work.
Official ratings
Medicare's star ratings compare nursing homes within the same state for health inspections. A 5-star facility performed better than most in its state; a 1-star facility performed worse than most.
Stars are calculated by CMS, not by us. We do not create our own safety score.
Serious documented violations
0Immediate jeopardy citations (severity J–L)
1Actual harm citations (severity G–I)
10Requirements cited on more than one inspection
G
Government finding: Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F600
Citations by topic
4Abuse, neglect & exploitation
6Infection control
4Medications & pharmacy
0Accidents & supervision
Topics use CMS's own deficiency categories; “accidents & supervision” counts tag F689 (free of accident hazards / adequate supervision). Counts cover the last three inspection cycles, including complaint investigations.
Is it getting better or worse?
More citations in the most recent cycle (31) than in the cycle before (15).
An inspection cycle is roughly one year and includes the standard inspection plus complaint investigations. Counts depend partly on how many complaint investigations occurred, so treat small changes with caution. Red bars include at least one serious citation.
Staffing and rating trends will appear as we collect monthly CMS releases. We have one month so far, so a staffing trend cannot yet be determined.
Repeat findings
These requirements were cited on more than one inspection date in the last three cycles.
| Requirement | Times cited | Inspection dates |
|---|---|---|
| Provide care and assistance to perform activities of daily living for any resident who is unable. (F677) | 3 | March 11, 2026; March 12, 2024; December 7, 2021 |
| Ensure each resident receives an accurate assessment. (F641) | 3 | March 11, 2026; March 12, 2024; December 7, 2021 |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. (F600) | 2 | March 11, 2026; June 9, 2025 |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. (F812) | 2 | March 11, 2026; March 12, 2024 |
| Provide and implement an infection prevention and control program. (F880) | 2 | March 11, 2026; March 12, 2024 |
| Provide routine and 24-hour emergency dental care for each resident. (F790) | 2 | March 11, 2026; March 12, 2024 |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. (F755) | 2 | March 11, 2026; December 7, 2021 |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. (F657) | 2 | March 11, 2026; March 12, 2024 |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. (F580) | 2 | March 11, 2026; March 12, 2024 |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. (F842) | 2 | March 11, 2026; March 12, 2024 |
Fines and enforcement
| Date | Type | Amount / length |
|---|---|---|
| March 11, 2026 | Fine | $111,404 |
| March 12, 2024 | Fine | $19,432 |
Federal civil money penalties and Medicare/Medicaid payment denials. State-level penalties may not be included.
Complete inspection history
April 14, 2026 — 1 citation · complaint investigation
D
Provide medically-related social services to help each resident achieve the highest possible quality of life.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F745 · complaint · corrected May 15, 2026
March 11, 2026 — 30 citations (includes serious)
G
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Actual harm to a resident (not immediate jeopardy) · Isolated · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F600 · corrected April 20, 2026
F
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
No actual harm, but potential for more than minimal harm · Widespread · Administration Deficiencies · F851 · corrected April 20, 2026
E
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
No actual harm, but potential for more than minimal harm · Pattern · Nursing and Physician Services Deficiencies · F947 · corrected April 20, 2026
E
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
No actual harm, but potential for more than minimal harm · Pattern · Infection Control Deficiencies · F882 · corrected April 20, 2026
E
Implement a program that monitors antibiotic use.
No actual harm, but potential for more than minimal harm · Pattern · Infection Control Deficiencies · F881 · corrected April 20, 2026
E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
No actual harm, but potential for more than minimal harm · Pattern · Nutrition and Dietary Deficiencies · F812 · corrected April 20, 2026
E
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.
No actual harm, but potential for more than minimal harm · Pattern · Pharmacy Service Deficiencies · F761 · corrected April 20, 2026
E
Ensure medication error rates are not 5 percent or greater.
No actual harm, but potential for more than minimal harm · Pattern · Pharmacy Service Deficiencies · F759 · corrected April 20, 2026
E
Observe each nurse aide's job performance and give regular training.
No actual harm, but potential for more than minimal harm · Pattern · Nursing and Physician Services Deficiencies · F730 · corrected April 20, 2026
E
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
No actual harm, but potential for more than minimal harm · Pattern · Nursing and Physician Services Deficiencies · F726 · corrected April 20, 2026
E
Provide care and assistance to perform activities of daily living for any resident who is unable.
No actual harm, but potential for more than minimal harm · Pattern · Quality of Life and Care Deficiencies · F677 · corrected April 20, 2026
D
Educate 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.
No actual harm, but potential for more than minimal harm · Isolated · Infection Control Deficiencies · F887 · corrected April 20, 2026
D
Develop and implement policies and procedures for flu and pneumonia vaccinations.
No actual harm, but potential for more than minimal harm · Isolated · Infection Control Deficiencies · F883 · corrected April 20, 2026
D
Provide and implement an infection prevention and control program.
No actual harm, but potential for more than minimal harm · Isolated · Infection Control Deficiencies · F880 · corrected April 20, 2026
D
Provide routine and 24-hour emergency dental care for each resident.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F790 · corrected April 20, 2026
D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
No actual harm, but potential for more than minimal harm · Isolated · Pharmacy Service Deficiencies · F755 · corrected April 20, 2026
D
Provide enough food/fluids to maintain a resident's health.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F692 · corrected April 20, 2026
D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F684 · corrected April 20, 2026
D
Ensure services provided by the nursing facility meet professional standards of quality.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F658 · corrected April 20, 2026
D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F657 · corrected April 20, 2026
D
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F644 · corrected April 20, 2026
D
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F628 · corrected April 20, 2026
D
Respond appropriately to all alleged violations.
No actual harm, but potential for more than minimal harm · Isolated · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F610 · corrected April 20, 2026
D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
No actual harm, but potential for more than minimal harm · Isolated · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F609 · corrected April 20, 2026
D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F580 · corrected April 20, 2026
D
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F559 · corrected April 20, 2026
D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F550 · corrected April 20, 2026
B
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
No actual harm, potential for minimal harm · Pattern · Resident Assessment and Care Planning Deficiencies · F842 · corrected April 20, 2026
B
Ensure each resident receives an accurate assessment.
No actual harm, potential for minimal harm · Pattern · Resident Assessment and Care Planning Deficiencies · F641 · corrected April 20, 2026
B
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
No actual harm, potential for minimal harm · Pattern · Resident Rights Deficiencies · F582 · corrected April 20, 2026
June 9, 2025 — 1 citation · complaint investigation
D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
No actual harm, but potential for more than minimal harm · Isolated · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F600 · complaint · corrected June 2, 2025
March 12, 2024 — 14 citations
E
Provide and implement an infection prevention and control program.
No actual harm, but potential for more than minimal harm · Pattern · Infection Control Deficiencies · F880 · corrected May 7, 2024
E
Hire a qualified full-time social worker in a facility with more than 120 beds.
No actual harm, but potential for more than minimal harm · Pattern · Administration Deficiencies · F850 · complaint · corrected March 15, 2024
E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
No actual harm, but potential for more than minimal harm · Pattern · Nutrition and Dietary Deficiencies · F812 · corrected March 15, 2024
E
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
No actual harm, but potential for more than minimal harm · Pattern · Resident Rights Deficiencies · F580 · corrected March 15, 2024
D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F842 · corrected March 15, 2024
D
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
No actual harm, but potential for more than minimal harm · Isolated · Nutrition and Dietary Deficiencies · F806 · corrected March 15, 2024
D
Provide routine and 24-hour emergency dental care for each resident.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F790 · corrected March 15, 2024
D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F698 · corrected March 15, 2024
D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F690 · corrected May 7, 2024
D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F686 · corrected March 15, 2024
D
Provide care and assistance to perform activities of daily living for any resident who is unable.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F677 · corrected March 15, 2024
D
Plan the resident's discharge to meet the resident's goals and needs.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F660 · corrected May 7, 2024
D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F657 · corrected March 15, 2024
B
Ensure each resident receives an accurate assessment.
No actual harm, potential for minimal harm · Pattern · Resident Assessment and Care Planning Deficiencies · F641 · corrected March 15, 2024
December 7, 2021 — 5 citations
E
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
No actual harm, but potential for more than minimal harm · Pattern · Pharmacy Service Deficiencies · F755 · corrected February 17, 2022
D
Provide safe and appropriate respiratory care for a resident when needed.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F695 · corrected February 17, 2022
D
Provide care and assistance to perform activities of daily living for any resident who is unable.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F677 · corrected February 17, 2022
D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F656 · corrected February 17, 2022
B
Ensure each resident receives an accurate assessment.
No actual harm, potential for minimal harm · Pattern · Resident Assessment and Care Planning Deficiencies · F641 · corrected February 17, 2022
Source: CMS Health Deficiencies dataset (data as of October 1, 2026); full inspection narratives on Medicare Care Compare