Autumn Lake Healthcare at Windsor

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for one of three residents (Resident #1) reviewed for abuse, the facility failed to ensure social service support visits were provided timely after an allegation of abuse.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for 3 of 5 residents (Resident's #93, #23 and #99) reviewed for abuse, the facility failed to ensure Resident #93 was free from verbal and physical abuse by his/her roommate Resident #41, and failed to ensure Resident 23 and 99, who were roommates, were free from abuse from each other.

Inspectors wroteBased on review of facility documentation and interviews, the facility failed to ensure accurate staffing data was entered in the Payroll Based Journal (PBJ) during FY Quarter 4 2025 (July1 -[DATE]).

Inspectors wroteBased on observation, review of the clinical record, facility documentation, facility policy and interviews for 3 of 3 residents, (Resident #12, 69 and 79) reviewed for activities of daily living (ADL) and who were unable to care for themselves, the facility failed provide basic care including bathing and toileting between 7:00 AM - 12:00 PM after the nurse aide assigned to provide care was reassigned and that information was not communicated to other staff.

Inspectors wroteBased on review of facility documentation, facility policy, facility assessment, and interviews, for 5 of 5 nurse aides (NA #8, 15, 16, 17, and 18) and 2 of 2 licensed nurses (LPN #5 and #8), reviewed for sufficient and competent nurse staffing, the facility failed to ensure the staff had demonstrated competencies necessary to care for resident's needs, from the last standard survey ([DATE]) through the change of ownership of the facility on [DATE].

Inspectors wroteBased on review of facility documentation, facility policy, and interviews, the facility failed to ensure 5 of 5 nurse aides (NA #8, 15, 16, 17, and 18) received a performance evaluation at least once every 12 months, from the last standard survey (3/12/24) through 2/24/26.

Inspectors wroteBased on observation, review of the clinical record, facility documentation, facility policy and interview the facility failed to ensure its medication error rate was not 5 percent or greater.

Inspectors wroteBased on observation, review of facility policy, and interviews, for 4 of 4 medication carts, the facility failed to maintain medication carts in a clean and sanitary manner.

Inspectors wroteBased on observation review of facility documentation, facility policy and interviews, the facility failed to ensure resident designated water pitches were clean and sanitized routinely.

Inspectors wroteBased on review of facility documentation, facility policies, and interviews, the facility failed to ensure an antibiotic stewardship program was in place that included a standardized tool for infection surveillance and a system for periodic review, from the last standard survey (3/12/24) through the change of ownership (11/1/25).

Inspectors wroteBased on review of facility documentation, facility policy and interviews, the facility failed to designate an infection preventionist (IP) at least part time to monitor the facility infection control program.

Inspectors wroteBased on review of facility documentation, facility policy, facility assessment, and interviews, the facility failed to ensure 5 of 5 nurse aides (NA #8, 15, 16, 17, and 18) reviewed for sufficient and competent nurse staffing, completed the minimum required 12-hours of in-service education, annually, from the last standard survey (3/12/24) through the change of ownership (11/1/25).

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy and interviews for 2 of 6 residents (Resident #16 and 110) reviewed for grievances, the facility failed to ensure the residents were treated in a respectful and dignified manner.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy and interviews for 1 of 5 residents (Resident #99) reviewed for resident rights, the facility failed to honor the residents request for a room change due to negative interactions with his/her roommate. Subsequently, the resident and his/her roommate had a resident-to-resident altercation.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 5 residents (Resident #93) reviewed for abuse, the facility failed to notify the physician and the resident representative of verbal and physical abuse by Resident #41 and for 2 of 5 residents (Resident #74 and 90) reviewed for nutrition, the facility failed to notify the physician of a significant weight gain in a timely manner.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for 3 of 5 residents (Resident #93, 23 and 99) reviewed for abuse, the facility failed to report allegations of abuse to the state agency according to regulatory requirement and facility policy.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for 3 of 5 residents (Resident #93, 23 and 99) reviewed for abuse, the facility failed to ensure the allegations of abuse were thoroughly investigated and the residents protected from future abuse.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for 4 residents (Resident #3, 8, 74, and 107) reviewed for hospitalization, the facility failed to ensure the Office of the State Long-Term Care Ombudsman was notified in accordance with regulatory requirements when the residents were transferred to the hospital.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy and interview for 1 of 3 residents, (Resident #7) reviewed for Preadmission Screening and Resident Review, PASARR, the facility failed ensure a reassessment was completed following the identification of a suspected mental illness.

Inspectors wroteBased on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 5 residents (Resident #41) reviewed for abuse, the facility failed to ensure that the resident's care plan was revised, and interventions were implemented following resident-to-resident altercations.

Inspectors wroteBased on observation, review of the clinical record, facility documentation, facility policy and interview for 1 of 5 residents (Residents #19) observed during medication administration, the facility failed to administer Levothyroxine according to professional standards.

Inspectors wroteBased on observation, review of the clinical record, facility documentation, facility policy, and interviews for 3 residents (Residents #93, 57 and 4) the facility failed to provide care according to professional standards. For 1 of 5 residents (Resident #93) reviewed for abuse, the facility failed to complete an RN assessment after a witnessed resident to resident altercation. For 1 of 2 residents (Resident #57) reviewed for pressure ulcers, the facility failed to ensure that the resident's heels were offloaded per the physician's order. For 1 of 5 residents (Resident #4) reviewed for unnecessary medications, the facility failed to consult the outside cardiologist for the resident regarding his/her implanted medical device.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for 3 of 5 residents (Resident #57, 90 and 74) reviewed for pressure ulcers and/or nutrition, for Resident #57, reviewed for pressure ulcers, the dietitian did not complete a nutritional assessment for 1 month, until surveyor inquiry, after a new wound was identified, for Resident #90, reviewed for nutrition, the facility failed to address a significant weight loss in a timely manner and for Resident #74, reviewed for nutrition, the facility failed to obtain a reweight for 2 weeks after the resident had a significant weight gain.

Inspectors wroteBased on observation, review of facility documentation, facility policy, and interviews for 1 of 4 medication carts, the facility failed to ensure shift to shift controlled drug counts were consistently completed.

Inspectors wroteBased on review of the clinical record, facility policy, and interviews for 1 of 5 residents (Resident #6) reviewed for unnecessary medications, the facility failed to ensure dental services with an oral surgeon were scheduled in timely manner.

Inspectors wroteBased on observation, review of the clinical record, facility documentation, facility policy, and interviews 2 residents (Resident #57 and 90) who were reviewed for wounds, the facility failed to implement enhanced barrier precautions (EBP) as per facility policy and professional standards.

Inspectors wroteBased on review of the clinical record, facility policy, and interviews for 2 of 5 residents (Residents #4 and 6) reviewed for immunizations, the facility failed to ensure the pneumococcal vaccine was administered in a timely manner.

Inspectors wroteBased on observation, review of the clinical record, facility documentation, facility policy, and interviews for 4 of 5 residents (Resident #4, 6, 8, and 99) reviewed for immunizations, the facility failed to ensure Covid-19 booster vaccines were administered in a timely manner.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy and interview for 4 of 4 residents (Resident #38, 68, 79 and 110) reviewed for beneficiary notification, the facility failed to provide the appropriate Medicare denial notices to the resident's upon being discharged from Medicare Part A with benefit days remaining.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy and interviews for 1 resident (Residents #6), reviewed for activity of daily living (ADL), the facility failed to ensure the resident's activity of daily living (ADL) were accurately coded in the Minimum Data Set (MDS) assessment.

Inspectors wroteBased on review of the clinical record, facility policy, and interviews for 2 of 5 residents (Residents #6 and 99) reviewed for unnecessary medications, the facility failed to ensure the medical records reflected accurate documentation that blood glucose readings outside of the ordered parameters were reported to the physician.

Inspectors wroteBased on clinical record reviews, facility documentation, facility policies and interviews for one (1) of three (3) sampled residents (Resident #1) who required set-up assistance from staff with personal hygiene and toileting, the facility failed to ensure a staff member did not verbalize profanity towards the resident.

Inspectors wroteBased on clinical record reviews, facility documentation, facility policy and interviews for 1 of 6 sampled residents (Resident #30) reviewed for non-pressure skin conditions, the facility failed to ensure the physician was notified of a newly identified non-pressure skin condition(s) in a timely manner.

Inspectors wroteBased on observations, facility documentation and interviews, the facility failed to ensure that foods were stored and prepared under sanitary conditions.

Inspectors wroteBased on clinical record reviews, facility documentation and interviews for 4 of 5 residents, (Resident 23, #28, #49 and #498) reviewed for quarterly social service review, the facility failed to conduct quarterly social service visits timely.

Inspectors wroteBased on observation, interview, and review of facility policy for 1 of 3 bathrooms, the facility failed to ensure resident care equipment was stored in a sanitary manner according to infection control practices and for 1 of 6 sampled residents (Resident #30) reviewed for non-pressure skin conditions, the facility failed to ensure wound care was performed in accordance with infection control standards regarding hand hygiene.

Inspectors wroteBased on observations, review of the clinical records, facility documentation, facility policy and interviews for 1 of 10 sampled residents (Resident #26) reviewed for abuse, the facility failed to ensure the comprehensive care plan was revised to reduce the risk of further physical mistreatment following a resident-to-resident physical altercation where Resident #70 was the victim. For 2 of 6 residents, (Resident #30 and #42), the facility failed to revise the care plan following a newly developed non pressure injury For Resident #43, the facility failed to ensure the care plan was revised in atimely manner following an allegation of abuse.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 2 residents (Resident # 78) reviewed for discharge, the facility failed to ensure that other state agencies were notified of the resident's decision to (Leave Against Medical Advice).

Inspectors wroteBased on clinical record review, observation, review of facility documentation, review of facility policy, and interviews for 1 of 3 sampled residents (Resident #46) reviewed for Activities of Daily Living (ADL). The facility failed to follow the resident plan of care.

Inspectors wroteBased on clinical record review, facility policy and interview for 1 of 3 sampled residents ( Resident # 51) at risk for pressure ulcer development, the facility failed to perform a weekly skin assessments as directed in the plan of care.

Inspectors wroteBased on review of the clinical record, facility policy, and interviews for 1 of 4 residents (Resident # 275) reviewed for abuse, the facility failed to assist implement a bowel retraining program when the resident was identified as a good candidate for retraining.

Inspectors wroteBased on record review, observation, review of facility policy and staff interviews for 1 of 1 resident, (Resident #20), reviewed for specialized treatment, the facility failed to ensure that the specialized treatment communication log was consistently completed before the resident left for the specialized treatments.

Inspectors wroteBased on review of the clinical record, facility documentation, and interviews for 1 of 3 residents (Resident #7) reviewed for dental, the facility failed to arrange dental appointment and assist with transportation timely.

Inspectors wroteBased on review of the clinical record and interviews for 1 of 2 residents (Resident #248) reviewed for food quality, the facility failed to ensure a resident with a severe seafood allergy did not receive fish during a meal.

Inspectors wroteBased on clinical record review, facility policy and interviews for 1 of 6 sampled residents (Resident #30) reviewed for non-pressure skin conditions, the facility failed to ensure a complete and accurate clinical record for a resident with newly identified non- pressure wound(s).

Inspectors wroteBased on clinical record reviews, facility documentation, facility policy and interviews for 3 of 3 residents (Residents # 7, 22 and 78) reviewed for Preadmission Screening and Resident Review ( PASRR) and for 1 of 3 residents (Resident # 59) reviewed for pressure ulcers, the facility failed to accurately code the Minimum Data Set (MDS) assessment.

Inspectors wroteBased on observation, review of facility documentation, facility policy review and interviews for one of three nursing units ( South Unit) review of the Controlled Drug Count Record Sheet (CDCRS) for reconciliation, the facility failed to consistently reconcile or sign off on the CDCRS for controlled medications every shift.

Inspectors wroteBased on clinical record reviews, facility policy and interviews for one of three residents reviewed for accidents (Resident #341) failed to develop a comprehensive plan of care for the resident's Leave of Absence (LOA) and for one of three residents reviewed for Activities of Daily Living (ADL) (Resident #11), the facility failed to develop and implement a comprehensive care plan consistent with resident's participation in treatment.

Inspectors wroteBased on review of the clinical record, review of facility policy and interviews for one of three residents (Resident #3) reviewed for ADL, the facility failed to provide care per resident's preferences.

Inspectors wroteBased on clinical record review, review of facility documentation and interviews for one resident (Resident #3) reviewed for respiratory care, the facility failed obtain active physician's order for the resident's tracheostomy.

Inspectors wroteBased on clinical record reviews, facility policy and interviews for 2 of 3 residents (Resident #60 and Resident #89) reviewed for Resident Assessment, the facility failed to accurately reflect the resident's status on the assessment.