CONTACT INFORMATION REVIEWS & MORE DATA
Deficiency Records for Autumn Lake Healthcare at Windsor
View the most recent health deficiencies and inspection results for Autumn Lake Healthcare at Windsor. Stay informed about quality of care issues.
View the most recent health deficiencies and inspection results for Autumn Lake Healthcare at Windsor. Stay informed about quality of care issues.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Meet other general requirements. | Fire Safety | 2026-03-11 | 2026-05-22 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2026-03-11 | 2026-05-22 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2026-03-11 | 2026-05-22 | N |
| Ensure that any exit in an area undergoing construction, repair, or improvements shall be inspected daily to ensure its ability to be used instantly in case of emergency. | Fire Safety | 2026-03-11 | 2026-05-22 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2026-03-11 | 2026-05-22 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2026-03-11 | 2026-05-22 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2026-03-11 | 2026-05-22 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2026-03-11 | 2026-05-22 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2026-03-11 | 2026-05-22 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2026-03-11 | 2026-05-22 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2026-03-11 | 2026-05-22 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2026-03-11 | 2026-05-22 | N |
| Have exits that are accessible at all times. | Fire Safety | 2026-03-11 | 2026-05-22 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2026-03-11 | 2026-05-22 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2026-03-11 | 2026-05-22 | N |
| Respond appropriately to all alleged violations. | Health | 2026-04-14 | 2026-05-15 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2026-04-14 | 2026-05-15 | Y |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2026-04-14 | 2026-05-15 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2026-03-11 | 2026-04-20 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2026-03-11 | 2026-04-20 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2026-03-11 | 2026-04-20 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2026-03-11 | 2026-04-20 | N |
| Respond appropriately to all alleged violations. | Health | 2026-03-11 | 2026-04-20 | N |
| Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. | Health | 2026-03-11 | 2026-04-20 | N |
| Ensure each resident receives an accurate assessment. | Health | 2026-03-11 | 2026-04-20 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2026-03-11 | 2026-04-20 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2026-03-11 | 2026-04-20 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2026-03-11 | 2026-04-20 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2026-03-11 | 2026-04-20 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2026-03-11 | 2026-04-20 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2026-03-11 | 2026-04-20 | N |
| 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. | Health | 2026-03-11 | 2026-04-20 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2026-03-11 | 2026-04-20 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2026-03-11 | 2026-04-20 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2026-03-11 | 2026-04-20 | N |
| 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. | Health | 2026-03-11 | 2026-04-20 | N |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2026-03-11 | 2026-04-20 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2026-03-11 | 2026-04-20 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2026-03-11 | 2026-04-20 | N |
| Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. | Health | 2026-03-11 | 2026-04-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2026-03-11 | 2026-04-20 | N |
| Implement a program that monitors antibiotic use. | Health | 2026-03-11 | 2026-04-20 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2026-03-11 | 2026-04-20 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2026-03-11 | 2026-04-20 | N |
| 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. | Health | 2026-03-11 | 2026-04-20 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2026-03-11 | 2026-04-20 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2026-03-11 | 2026-04-20 | N |
| Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. | Health | 2026-03-11 | 2026-04-20 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2025-06-09 | 2025-06-02 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-03-12 | 2024-05-07 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2024-03-12 | 2024-05-07 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2024-03-12 | 2024-05-07 | N |
| Hire a qualified full-time social worker in a facility with more than 120 beds. | Health | 2024-03-12 | 2024-03-15 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-03-12 | 2024-03-15 | N |
| Ensure each resident receives an accurate assessment. | Health | 2024-03-12 | 2024-03-15 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2024-03-12 | 2024-03-15 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-03-12 | 2024-03-15 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-03-12 | 2024-03-15 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2024-03-12 | 2024-03-15 | N |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2024-03-12 | 2024-03-15 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2024-03-12 | 2024-03-15 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-03-12 | 2024-03-15 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-03-12 | 2024-03-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-03-12 | 2024-03-14 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2024-03-12 | 2024-03-07 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-03-12 | 2024-02-28 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2024-03-12 | 2024-02-27 | N |
| Establish emergency prep training and testing. | Fire Safety | 2024-03-12 | 2024-02-27 | N |
| Establish staff and initial training requirements. | Fire Safety | 2024-03-12 | 2024-02-27 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2024-03-12 | 2024-02-27 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2024-03-12 | 2024-02-27 | N |
| Ensure proper storage of liquid oxygen. | Fire Safety | 2024-03-12 | 2024-02-27 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-03-12 | 2024-02-27 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2024-03-12 | 2024-02-27 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2024-03-12 | 2024-02-27 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2024-03-12 | 2024-02-27 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2024-03-12 | 2024-02-27 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2024-03-12 | 2024-02-27 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-03-12 | 2024-02-27 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2024-03-12 | 2024-02-27 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2024-03-12 | 2024-02-27 | N |
| Meet requirements for operating features, such as evacuation plans, fire drills, smoking regulations, draperies, decorations and the inspection, testing and maintenance of fire doors. | Fire Safety | 2024-03-12 | 2024-02-27 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-12-07 | 2022-02-17 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-12-07 | 2022-02-17 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-12-07 | 2022-02-17 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-12-07 | 2022-02-17 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-12-07 | 2022-02-17 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-12-07 | 2022-01-28 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-12-07 | 2022-01-28 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2021-12-07 | 2022-01-28 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-12-07 | 2022-01-28 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2021-12-07 | 2022-01-28 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2021-12-07 | 2022-01-28 | N |