Autumn Lake Healthcare at the Willows

In the surveyor’s words

From the most serious findings on record at Autumn Lake Healthcare at the Willows, in the surveyor’s own words.

• Actual harm, isolatedF686Jul 13, 2021

  Based on clinical record reviews, review of facility policy, and interviews for one of three sampled residents (Resident #1) who was at risk for skin breakdown due to limited mobility, the facility failed to implement an intervention prior to development of a Deep Tissue Injury pressure ulcer, to conduct weekly assessments after the pressure area was identified, and failed to notify the Dietician of the pressure ulcer per the facility policy. The findings include: Resident #1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, widespreadF802Jan 10, 2024

  Based on the tour of the Dietary Department and staff interview, the facility failed to ensure adequate staffing to carry out the functions for cleaning the kitchen. The findings included: Tour of the Dietary Department on [DATE] at 11:10 AM during the initial walk through of the kitchen with the Dietary Manager (DM) identified the following: a. The windowsill above the lids for the tray line and toaster was noted with dust, debris and observed with a brown substance. b. The windowsill outside the DM's office near the refrigerator was noted with a heavy accumulation of dust. c. The coffee maker and coffee maker station was stained and discolored with debris noted on the coffee pots and counter. d. Tray carts #2 and #3 were both noted to be soiled with dust/debris. […]

• No harm, potential for more than minimal, widespreadF812Jan 10, 2024

  Based on the tour of the Dietary Department and staff interview, the facility failed to ensure the Dietary department was maintained in a clean, sanitary manner and that food items were consistently labeled and stored to reflect their age or shelf life. The findings included: Tour of the Dietary Department on [DATE] at 11:10 AM during the initial walk through of the kitchen with the Dietary Manager (DM) identified the following: a. The dishwasher room was observed to have ceiling tiles with a brown substance noted on them and 1 was loose. b. The light panel in the dishwasher room had 2 cracks, 1 at each end of it along with having a brown substance on it. c. The windowsill above the lids for the tray line use and the toaster had debris noted with a brown substance throughout. d. […]

• No harm, potential for more than minimal, patternF761Nov 14, 2025

  Based on observation, review of facility documentation, facility policy and interview, the facility failed to ensure ophthalmic medications were labeled properly after opening. The findings include:Observation on 9/16/25 at 10:20 AM of 4 of 6 medication cart inspections identified the following ophthalmic medication, which were open, had no documented dates regarding when they were open. a. Medication cart identified as 2nd floor long hall.1 bottle of brimonidine tartrate 0.2% eye drops.1 bottle of Systane eye drops.1 bottle of Refresh eye drops. b. […]

• No harm, potential for more than minimal, patternF883Nov 14, 2025

  Based on review of facility documentation, facility policy and interviews for 4 of 5 residents, (Resident #3, 9, 12 and 75) reviewed for pneumococcal and influenza vaccine administration, the facility failed to ensure informed consent and documented administration of pneumococcal and influenza vaccinations was done according to policy. The findings include: 1. Resident #3 was admitted to the facility in April 2022 with diagnoses that included cerebral palsy and mitral insufficiency. Resident #3 was self-responsible.A review of Resident #3's immunization record identified the pneumococcal vaccine (PV20) was administered on 4/28/23.The Pneumococcal Vaccine Informed Consent form dated 4/28/23 identified no documented signed consent for the pneumococcal vaccine. 2. […]