Safety Report: Autumn Lake Healthcare At Ballenger Creek
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
1Immediate jeopardy citations (severity J–L)
1Actual harm citations (severity G–I)
20Requirements cited on more than one inspection
J
Government finding: Ensure that residents are free from significant medication errors.
Pharmacy Service Deficiencies · Tag F760
G
Government finding: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies · Tag F689
Citations by topic
7Abuse, neglect & exploitation
4Infection control
8Medications & pharmacy
2Accidents & 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?
Fewer citations in the most recent cycle (22) than in the cycle before (25).
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 and implement an infection prevention and control program. (F880) | 3 | June 30, 2026; June 30, 2025; November 15, 2022 |
| Provide care and assistance to perform activities of daily living for any resident who is unable. (F677) | 3 | June 30, 2026; June 30, 2025; November 15, 2022 |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. (F657) | 3 | June 30, 2026; June 30, 2025; November 15, 2022 |
| Ensure each resident receives an accurate assessment. (F641) | 3 | June 4, 2026; June 30, 2025; November 15, 2022 |
| Respond appropriately to all alleged violations. (F610) | 3 | November 20, 2025; June 30, 2025; November 15, 2022 |
| 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. (F585) | 3 | November 20, 2025; June 30, 2025; November 15, 2022 |
| Provide safe, appropriate pain management for a resident who requires such services. (F697) | 2 | June 30, 2026; June 30, 2025 |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. (F686) | 2 | June 30, 2026; June 30, 2025 |
| Assess the resident when there is a significant change in condition (F637) | 2 | June 30, 2026; June 30, 2025 |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. (F636) | 2 | June 30, 2026; June 30, 2025 |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. (F584) | 2 | June 30, 2026; June 30, 2025 |
| Provide appropriate treatment and care according to orders, resident’s preferences and goals. (F684) | 2 | June 4, 2026; November 15, 2022 |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. (F609) | 2 | November 20, 2025; June 30, 2025 |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. (F842) | 2 | June 30, 2025; November 15, 2022 |
| Ensure that residents are free from significant medication errors. (F760) | 2 | June 30, 2025; November 15, 2022 |
| Provide activities to meet all resident's needs. (F679) | 2 | June 30, 2025; November 15, 2022 |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. (F656) | 2 | June 30, 2025; November 15, 2022 |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. (F756) | 2 | June 30, 2025; November 15, 2022 |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. (F689) | 2 | June 30, 2025; November 15, 2022 |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. (F578) | 2 | June 30, 2025; November 15, 2022 |
Fines and enforcement
No federal fines or payment denials in the last three years.
Federal civil money penalties and Medicare/Medicaid payment denials. State-level penalties may not be included.
Complete inspection history
June 30, 2026 — 16 citations
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 August 14, 2026
D
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
No actual harm, but potential for more than minimal harm · Isolated · Nutrition and Dietary Deficiencies · F805 · corrected August 14, 2026
D
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
No actual harm, but potential for more than minimal harm · Isolated · Nutrition and Dietary Deficiencies · F804 · corrected August 14, 2026
D
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 · Isolated · Pharmacy Service Deficiencies · F761 · corrected August 14, 2026
D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
No actual harm, but potential for more than minimal harm · Isolated · Pharmacy Service Deficiencies · F757 · corrected August 14, 2026
D
Provide safe, appropriate pain management for a resident who requires such services.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F697 · corrected August 14, 2026
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 August 14, 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 August 14, 2026
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 August 14, 2026
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 August 14, 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 August 14, 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 August 14, 2026
D
Assess the resident when there is a significant change in condition
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F637 · corrected August 14, 2026
D
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F636 · corrected August 14, 2026
D
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F584 · corrected August 14, 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 August 14, 2026
June 4, 2026 — 2 citations · complaint investigation
E
Ensure each resident receives an accurate assessment.
No actual harm, but potential for more than minimal harm · Pattern · Resident Assessment and Care Planning Deficiencies · F641 · complaint · corrected July 10, 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 · complaint · corrected July 10, 2026
November 20, 2025 — 4 citations · complaint investigation
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 · complaint · corrected January 16, 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 · complaint · corrected January 16, 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 · complaint · corrected January 16, 2026
D
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.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F585 · complaint · corrected January 16, 2026
June 30, 2025 — 25 citations
F
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 · Widespread · Infection Control Deficiencies · F887 · corrected August 1, 2025
F
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 · Widespread · Nutrition and Dietary Deficiencies · F812 · corrected August 1, 2025
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 August 1, 2025
E
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 · Pattern · Resident Assessment and Care Planning Deficiencies · F842 · corrected August 1, 2025
E
Ensure that residents are free from significant medication errors.
No actual harm, but potential for more than minimal harm · Pattern · Pharmacy Service Deficiencies · F760 · corrected August 1, 2025
E
Provide activities to meet all resident's needs.
No actual harm, but potential for more than minimal harm · Pattern · Quality of Life and Care Deficiencies · F679 · corrected August 1, 2025
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 · complaint · corrected August 1, 2025
E
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 · Pattern · Resident Assessment and Care Planning Deficiencies · F656 · corrected August 1, 2025
E
Ensure each resident receives an accurate assessment.
No actual harm, but potential for more than minimal harm · Pattern · Resident Assessment and Care Planning Deficiencies · F641 · corrected August 1, 2025
E
Assess the resident when there is a significant change in condition
No actual harm, but potential for more than minimal harm · Pattern · Resident Assessment and Care Planning Deficiencies · F637 · corrected August 1, 2025
E
Respond appropriately to all alleged violations.
No actual harm, but potential for more than minimal harm · Pattern · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F610 · complaint · corrected August 1, 2025
D
Keep all essential equipment working safely.
No actual harm, but potential for more than minimal harm · Isolated · Environmental Deficiencies · F908 · complaint · corrected August 1, 2025
D
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
No actual harm, but potential for more than minimal harm · Isolated · Pharmacy Service Deficiencies · F756 · corrected August 1, 2025
D
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F740 · corrected August 1, 2025
D
Provide safe, appropriate pain management for a resident who requires such services.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F697 · corrected August 1, 2025
D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F689 · corrected August 1, 2025
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 · complaint · corrected August 1, 2025
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 August 1, 2025
D
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F636 · corrected August 1, 2025
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 · complaint · corrected August 1, 2025
D
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.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F585 · corrected August 1, 2025
D
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F584 · corrected August 1, 2025
D
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F578 · corrected August 1, 2025
D
Reasonably accommodate the needs and preferences of each resident.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F558 · corrected August 1, 2025
D
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F557 · corrected August 1, 2025
November 15, 2022 — 24 citations (includes serious)
J
Ensure that residents are free from significant medication errors.
Immediate jeopardy to resident health or safety · Isolated · Pharmacy Service Deficiencies · F760 · corrected June 15, 2022
G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Actual harm to a resident (not immediate jeopardy) · Isolated · Quality of Life and Care Deficiencies · F689 · corrected January 16, 2023
F
Observe each nurse aide's job performance and give regular training.
No actual harm, but potential for more than minimal harm · Widespread · Nursing and Physician Services Deficiencies · F730 · corrected January 16, 2023
F
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
No actual harm, but potential for more than minimal harm · Widespread · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F607 · corrected January 16, 2023
E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
No actual harm, but potential for more than minimal harm · Pattern · Quality of Life and Care Deficiencies · F684 · corrected January 16, 2023
E
Provide activities to meet all resident's needs.
No actual harm, but potential for more than minimal harm · Pattern · Quality of Life and Care Deficiencies · F679 · corrected January 16, 2023
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 January 16, 2023
E
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 · Pattern · Resident Assessment and Care Planning Deficiencies · F657 · corrected January 16, 2023
E
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 · Pattern · Resident Assessment and Care Planning Deficiencies · F656 · corrected February 16, 2023
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 January 16, 2023
D
Have a plan that describes the process for conducting QAPI and QAA activities.
No actual harm, but potential for more than minimal harm · Isolated · Administration Deficiencies · F865 · corrected January 16, 2023
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 January 16, 2023
D
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
No actual harm, but potential for more than minimal harm · Isolated · Pharmacy Service Deficiencies · F758 · corrected January 16, 2023
D
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
No actual harm, but potential for more than minimal harm · Isolated · Pharmacy Service Deficiencies · F756 · corrected January 16, 2023
D
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
No actual harm, but potential for more than minimal harm · Isolated · Nursing and Physician Services Deficiencies · F711 · corrected January 16, 2023
D
Ensure the activities program is directed by a qualified professional.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F680 · corrected January 16, 2023
D
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F655 · corrected January 16, 2023
D
Ensure each resident receives an accurate assessment.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F641 · corrected February 16, 2023
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 January 16, 2023
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 · corrected January 16, 2023
D
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.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F585 · corrected January 16, 2023
D
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F578 · corrected January 16, 2023
C
Post nurse staffing information every day.
No actual harm, potential for minimal harm · Widespread · Nursing and Physician Services Deficiencies · F732 · corrected January 16, 2023
B
Let each resident or the resident's legal representative access or purchase copies of all the resident's records.
No actual harm, potential for minimal harm · Pattern · Resident Rights Deficiencies · F573 · corrected January 16, 2023
Source: CMS Health Deficiencies dataset (data as of October 1, 2026); full inspection narratives on Medicare Care Compare