Autumn Lake Healthcare at Windsor

In the surveyor’s words

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

• Immediate jeopardy, isolatedF600Mar 12, 2024

  Based on observations, clinical record reviews, review of facility documentation, review of policy and staff interviews for 1 of 5 sampled residents (Resident # 60) reviewed for abuse, the facility failed to ensure the resident was free from abuse and failed to protect other residents following a resident-to-resident altercation resulting in the finding of Immediate Jeopardy and for 4 of 10 residents (Resident # 36, # 43, # 70, # 76), reviewed for abuse, the facility failed to ensure the residents were free from mistreatment. […]

• Actual harm, patternF697Mar 10, 2022

  Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident # 9) reviewed for pain, the facility failed to ensure a resident received prescribed pain medication in a timely manner, failed to implement any further interventions when pain relief was ineffective resulting in severe pain. The findings include: Resident #9 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #9 was without cognitive impairment, required extensive assist with bed mobility, transfers, personal care and had experienced frequent pain. […]

• Actual harm, isolatedF600Mar 11, 2026

  Based 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. The findings include: 1a. Resident #93 was admitted to the facility in May 2024 with diagnoses that included schizophrenia, psychosis, and adjustment disorder. The clinical record identified Resident #41 had a room change to Resident #93's room on 3/13/25. The care plan dated 4/28/25 identified Resident #93 had potential for impaired thought processes related to difficulty expressing him/herself. […]

• Actual harm, isolatedF656Apr 25, 2023

  Based on clinical record review, observations, facility documentation review, facility policy review and interviews for one of three residents (Resident #1) reviewed for abuse, the facility failed to ensure staff transferred the resident in accordance with the plan of care. The findings include: Resident #1's diagnoses included cerebral infarction, dementia, adult failure to thrive, anxiety disorder, and disorders of bone density and structure. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had severe cognitive impairment and required extensive assistance of two (2) staff for transfers. […]

• No harm, potential for more than minimal, widespreadF851Mar 11, 2026

  Based 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]). The findings include: Review of the PBJ Staffing Data Report dated FY Quarter 4 2025 (July1 -[DATE]) identified that the facility triggered for a one star staffing rating, no RN hours on the following dates: 9/19/25, 9/20/25, 9/22/25, 9/23/25, 9/24/25, 9/25/25, 9/26/25, 9/27/25, 9/29/25, and 9/30/25, and failure to have licensed nurse coverage 24 hours/day on the following dates: 9/19/25, 9/20/25, 9/22/25, 9/23/25, 9/24/25, 9/25/25, 9/26/25, 9/27/25, 9/29/25, and 9/30/25. […]