Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Autumn Woods Residential Health during CMS and state inspections, most recent first.
A hospice resident with CREST Syndrome Scleroderma and Rheumatoid Arthritis, who was cognitively intact, reported waking in severe morning pain and stated they wanted to be awakened for nighttime pain medication. Review of the care plan and orders showed scheduled morphine every four hours plus PRN dosing for breakthrough pain, but the MAR documented multiple missed midnight doses, with nursing staff recording that the medication was not given because the resident was sleeping. The UM and DON confirmed the doses were not administered despite orders and policies requiring pain management consistent with the resident’s care plan and expressed preferences.
A resident with Alzheimer’s dementia, admitted from a hospital and unable to complete a BIMs assessment, was identified by nursing staff as exit seeking during the first night but no specific elopement-prevention interventions were implemented. The resident repeatedly left their room overnight and required redirection, and the oncoming nurse verbally told CNAs to keep an eye on the resident. The next morning, while staff were passing breakfast trays and an LPN was doing a med pass near the smoker’s exit, the resident sat near the smoking area doors and then left the building by following a smoker through an unlocked, non-alarmed interior door routinely used for independent smoking. The resident walked off the premises and was later located at a nearby medical clinic and returned, with staff and internal review concluding that the resident had been assessed as an elopement risk but was not provided with appropriate interventions to prevent leaving the facility.
Several residents with severe cognitive impairment and total dependence on staff were repeatedly observed without accessible call lights, as devices were found on the floor, out of reach, or improperly placed. This occurred despite facility policy requiring call lights to be accessible and accommodations to be made for individual needs.
A resident with moderate cognitive impairment and multiple medical conditions repeatedly requested a room change due to dissatisfaction with their environment, lack of access to personal belongings, and frequent intrusions by other residents. Despite these requests and staff acknowledgment of an overstimulating environment, the facility did not address the resident's preferences or provide a room change policy, and no documented behaviors justified the resident's placement on a locked unit.
A resident with severe cognitive impairment and multiple comorbidities was discharged with unexplained bruising in various stages of healing, despite initial assessments showing no skin issues. Staff failed to thoroughly assess and document these injuries, and the facility could not determine the cause of most bruises. The required daily skin checks and reporting procedures were not followed, leading to a deficiency in protecting the resident from potential abuse or neglect.
A resident with a history of falls and requiring assistance with mobility was repeatedly observed without the prescribed fall mat next to the bed, as outlined in the care plan. Despite the care plan intervention, the fall mat was not in place during multiple observations, and staff could not account for its absence. Incident reports and the facility's fall policy were not provided during the survey.
A resident's room was found with stained linens, a sticky floor, soiled baseboards, and feces on the toilet seat, despite facility procedures requiring daily cleaning and disinfection. The DON confirmed the room required cleaning, and the resident had severe cognitive impairment but was independent in mobility.
A resident's privacy was compromised due to improperly placed cameras in their room, which faced the entry door and allowed monitoring by the resident's mother. The cameras' positioning potentially infringed on the privacy of others in the hallway. The resident had severe cognitive impairment and was non-verbal, requiring full assistance from staff. Despite being informed of the privacy concerns, the resident's mother insisted on her right to place the cameras as she wished.
A resident with cognitive impairment and mobility issues was verbally and physically abused by an LPN, who yelled profanities and lifted a couch to force the resident off, causing them to fall. The incident was witnessed by staff and reported to the Assistant Director of Nursing. The facility's abuse policy was violated as residents are entitled to be free from all forms of abuse.
A resident was subjected to verbal and physical abuse by an LPN, who yelled profanities and lifted the couch the resident was lying on, causing them to fall. The incident, witnessed by a nurse and a CNA, was not reported to the SA until two days later, constituting a delay in reporting abuse allegations.
The facility failed to maintain proper sanitation and food safety standards, as observed with ineffective sanitizer buckets and improperly dried dishware in the kitchen. Additionally, resident refrigerators contained undated and expired food items, violating the facility's food safety policies.
The facility failed to provide adequate personal care for three residents, resulting in deficiencies in activities of daily living (ADLs). A resident with Parkinsonism did not receive scheduled showers, another with hemiplegia was not shaved during bed baths, and a third resident had excessively long toenails. Staff cited equipment shortages and scheduling issues, but the care plans and facility policies were not followed.
The facility failed to document and date PICC line dressings for two residents. One resident had a gauze dressing without a date or transparent cover, and the insertion site was not visible. The LPN and Unit Manager acknowledged the oversight. The second resident's transparent dressing was undated, and records lacked documentation of dressing changes. The DON confirmed the requirement for transparent, dated dressings and regular assessments.
A resident fell from a mechanical lift due to a ripped sling, with only one CNA present, contrary to policy requiring two staff. Additionally, a resident was observed using a vape pen in their room, violating the facility's smoking policy. These deficiencies highlight lapses in policy enforcement regarding mechanical lift use and smoking materials management.
The facility failed to securely store medications for four residents. One resident had a pill on their overbed table, another had a capsule on their window sill, a third had an inhaler on their table, and a fourth had a bag of pills they were not taking. The facility's policy requires medications to be taken with a nurse present and refused medications to be removed.
A resident with a recent above-knee amputation reported that their bed's height adjustment was non-functional, making a loud grinding noise. Despite informing multiple staff members, including maintenance and nursing staff, the issue was not addressed. Interviews revealed that staff were aware of the problem but did not report it. The Maintenance Director was unaware of the issue due to the absence of work orders, and the facility lacked a policy for reporting malfunctioning equipment.
Failure to Administer Scheduled Morphine for Hospice Resident’s Nighttime Pain
Penalty
Summary
Surveyors identified a failure to provide ordered pain management when nursing staff did not administer scheduled morphine doses to a hospice resident as prescribed. The resident, admitted with CREST Syndrome Scleroderma and Rheumatoid Arthritis and assessed as cognitively intact, reported waking up in severe pain in the mornings and believed they were not receiving their nighttime pain medication. The resident stated they wanted to be awakened for nighttime medication, even if asleep, so that their pain would not become severe. The resident’s care plan under hospice services included administering medications as ordered, observing for effectiveness, evaluating for signs and symptoms of pain, and providing care based on the resident’s end-of-life comfort preferences. Record review showed physician orders for morphine 100 mg/5 ml, 2 ml every four hours, and an additional PRN order for 2 ml every two hours for breakthrough pain. The MAR for March documented that seven scheduled midnight doses of morphine were not administered on multiple dates, with RN documentation indicating the medication was withheld because the resident was sleeping. The Unit Manager confirmed, based on the electronic record and narcotic sign-out sheets, that these doses were not given and stated the medication should have been administered unless the resident requested not to be awakened. The DON also stated that medications should be given as ordered. Facility policies on Pain Management and Hospice required that pain management be provided consistent with professional standards, the care plan, and resident goals and preferences, including directives for managing pain and uncomfortable symptoms.
Failure to Implement Elopement Interventions for Newly Admitted Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement interventions to monitor and prevent elopement for a newly admitted resident with Alzheimer’s dementia who had been identified as an elopement risk. The resident was admitted from a hospital with diagnoses including Alzheimer’s and dementia, was unable to complete a BIMs assessment, and did not recognize their own name on nursing assessment. During the night shift, the resident repeatedly left their room, required redirection, and was described by the nurse as exit seeking. The nurse reported this exit-seeking behavior to the oncoming nurse and indicated the resident might need transfer to a secured unit, and the oncoming nurse was heard telling CNAs they needed to keep an eye on the resident. Despite this, no specific elopement-prevention intervention was put in place prior to the incident. On the morning of the elopement, the resident was observed on video sitting in a hallway chair and then moving to a dayroom sofa near the smoker’s exit doors while staff, including a nurse with a medication cart and CNAs passing breakfast trays, were present in the area. A CNA last saw the resident around the time breakfast trays were finished, then went to give another resident a 15–20 minute shower. Within approximately 45 minutes, the resident was no longer on the sofa and could not be located by staff. The CNA who had last seen the resident reported they had not received any direct report from night-shift CNAs about the resident’s exit-seeking behavior and initially thought the resident was a visitor when first observed sitting in the hallway. The resident exited the building through the smoker’s patio area, which was routinely unlocked during the day for independent smokers and, at the time of the incident, did not have an alarm on the interior set of doors. Staff interviews and a resident smoker confirmed that the interior door alarms were new and had not been in place or activated when smokers went out during the day prior to the elopement. Video review showed the resident walking down the sidewalk from the employee entrance toward the front of the building, and the facility later learned the resident had followed another resident who went out to smoke. The resident was found at a nearby medical clinic and returned to the facility, where they were noted to be confused by basic questions. The root cause identified by the facility was that the resident had scored as a risk for elopement on admission, but staff did not implement an intervention to prevent the resident from leaving the facility.
Failure to Ensure Call Light Accessibility for Dependent Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach for four residents who were reviewed for care needs. Multiple observations over several days showed that these residents, all of whom had severely impaired cognition and were totally dependent on staff for activities of daily living, did not have access to their call lights while in bed. Specifically, call lights were found on the floor, looped over the call box or vent cart, or hanging below the bed frame, making them inaccessible to the residents. The residents involved had significant medical conditions, including renal failure, diabetes, malnutrition, respiratory failure, and stroke. Facility policy required that call lights be accessible at each resident's bedside and that special accommodations be provided as needed, but these requirements were not met for the residents observed. The deficiency was identified through direct observation, interviews, and record review.
Failure to Honor Resident Room Change Preference and Support Self-Determination
Penalty
Summary
The facility failed to honor a resident's preference for a room change, as well as other expressed choices, for one resident with moderate cognitive impairment and diagnoses including diabetes, hypertension, and dementia. The resident reported dissatisfaction with their care, specifically noting lack of access to their clothes due to a locked closet, not being allowed to leave the locked unit or go outside for an extended period, and frequent intrusions by other residents into their room. The resident stated that requests for a room change were made to both the unit manager and their guardian, but these requests were not addressed. Staff interviews confirmed that the environment was overstimulating for the resident, affecting their participation in meals and activities, and that staff availability limited the resident's ability to leave the unit for activities such as visiting the vending machine. Observations included another resident entering the affected resident's room and using their belongings, which the resident indicated was a recurring issue. Review of the medical record showed no documented behaviors that would necessitate placement on a locked unit, and the director of nursing confirmed there was no specific criteria for such placement. The resident's care plan and progress notes did not document behaviors justifying the current room assignment. Additionally, a request for the facility's room change policy was made but no policy was provided by the end of the survey.
Failure to Assess and Document Unexplained Bruising
Penalty
Summary
A resident admitted for a 7-day respite stay, with diagnoses including Alzheimer's Disease, severe protein-calorie malnutrition, and diabetes, was found to have multiple bruises of various stages of healing on discharge. Initial nursing and nurse practitioner assessments documented no skin integrity issues or visible rashes upon admission. The resident, who was severely cognitively impaired and required significant assistance with activities of daily living, was later observed by a CNA to have redness on the right arm on the day of discharge, which was reported to a nurse, though the specific nurse was not recalled. Documentation submitted to the State Agency included photos of bruises on the resident's neck, left shoulder, hand, chest, and shin, with some bruises appearing to be more advanced in healing than others. The facility's internal investigation could not substantiate the causes of all the bruises except for the hand, and the DON acknowledged that staff should have noticed the bruising during care. The facility's wound care policy required CNAs to check residents' skin daily and report any new findings to the charge nurse or unit management for immediate intervention, but this process was not followed, resulting in the failure to thoroughly assess and document the resident's skin bruising and injury of unknown origin.
Failure to Implement Fall Prevention Care Plan Intervention
Penalty
Summary
The facility failed to implement a fall care plan intervention for one resident who had a history of falls and required assistance with bed mobility and transfers. The resident, who had diagnoses of cerebral infarction and bipolar disorder and demonstrated intact cognition, was observed multiple times without the prescribed fall mat on the left side of the bed, despite the care plan specifying this intervention. The resident reported using a cane for mobility and acknowledged having experienced falls in the facility. During the survey, incident and accident reports for the resident were requested but not provided. Repeated observations confirmed the absence of the fall mat, and the unit manager was unable to explain why the intervention was not in place, suggesting maintenance may have moved it. The facility's policy related to falls was also requested but not received by the end of the survey. The deficiency centers on the facility's failure to ensure that care plan interventions to prevent falls were consistently implemented as documented.
Failure to Maintain Clean and Homelike Resident Environment
Penalty
Summary
Surveyors observed that a resident's room was not maintained in a clean and homelike condition as required. During an unannounced visit, the resident was found unresponsive to attempts at arousal, and the room contained unidentifiable brown stains on both the fitted and flat sheets where the resident was lying. The floor was sticky, the door had dried liquid stains, and the baseboards were coated with an unknown caked-on substance. Additionally, the resident's bathroom had feces present on the toilet seat. These observations were confirmed during a follow-up visit with the Director of Nursing, who acknowledged the need for cleaning. A review of the facility's cleaning procedures indicated that resident rooms are to be cleaned daily, including disinfecting sinks and toilets, mopping floors, and spot washing walls and doors when soiled. The resident involved had a history of Schizoaffective Disorder, muscle weakness, hypertension, and severe cognitive impairment, but was independent with transfers and bed mobility. Despite these protocols and the resident's needs, the room was not maintained according to the facility's standards at the time of the survey.
Privacy Violation Due to Improper Camera Placement
Penalty
Summary
The facility failed to maintain privacy for a resident, identified as R704, due to the improper placement of electronic monitoring devices in the resident's room. Observations revealed that two cameras were positioned in a manner that allowed them to face the room's entry door, potentially infringing on the privacy of other residents and staff in the hallway. The cameras were connected to the resident's mother's phone, allowing her to monitor the room in real-time and hear conversations. The Assistant Nursing Home Administrator confirmed that the cameras were incorrectly positioned and should have been facing only the resident. R704 was a resident with a severely impaired cognitive condition, non-verbal, and dependent on staff for all mobility and activities of daily living. The Director of Nursing contacted R704's mother to address the camera placement issue, explaining that the current positioning could violate the privacy of others. However, R704's mother insisted on her right to place the cameras as she wished, leading to a conflict between respecting the resident's family's wishes and maintaining the privacy and dignity of other residents.
Failure to Prevent Resident Abuse by Staff
Penalty
Summary
The facility failed to prevent verbal and physical abuse of a resident, identified as R801, by a staff member. On the midnight shift of 10/13/2024, LPN C was observed by Nurse D and CNA E yelling profanities at R801, who was trying to sleep on a couch in the dayroom. When R801 refused to get up, LPN C continued to yell and then physically lifted the couch, causing R801 to roll onto the floor. This incident was reported to the Assistant Director of Nursing by the observing staff members. R801, who was admitted with diagnoses including the presence of a right artificial joint and depression, required staff assistance with bed mobility and transfers. The resident was unable to complete a mental status assessment, indicating significant cognitive impairment. A family member, who is also the guardian, was not informed that a staff member was involved in the fall. The facility's abuse policy clearly states that residents have the right to be free from all forms of abuse, which was violated in this incident.
Failure to Timely Report Abuse Allegation
Penalty
Summary
The facility failed to report an abuse allegation in a timely manner involving a resident, identified as R801. The incident occurred during the midnight shift when an LPN was observed yelling profanities at R801 for trying to sleep on the couch in the dayroom. When the resident refused to get up, the LPN continued to yell and then physically lifted the couch, causing the resident to roll onto the floor. This incident was witnessed by a nurse and a CNA, who reported it to the Assistant Director of Nursing (ADON) the following morning. Despite the incident occurring on 10/12/2024, it was not reported to the State Agency (SA) until 10/14/2024. The delay in reporting was acknowledged by the ADON, who stated that the incident should have been reported immediately. The staff involved were subsequently educated on the proper procedures for reporting abuse allegations. The failure to report the incident promptly constituted a deficiency in the facility's compliance with regulations regarding the timely reporting of abuse allegations.
Deficiencies in Kitchen Sanitation and Food Storage
Penalty
Summary
The facility failed to maintain proper sanitation and food safety standards in the kitchen and resident food storage areas. During an initial tour of the kitchen, it was observed that two red sanitizer buckets with wiping cloths did not contain an effective sanitizer solution, as confirmed by a test strip that failed to change color. Additionally, stacks of metal pans were found with visible water droplets, indicating they were not properly dried before stacking, which is against the 2017 FDA Food Code requirements for air drying utensils. Further inspection of the resident refrigerators revealed multiple undated food containers and expired food items, such as a bag of cut watermelon dated over a week prior and several black, mushy bananas. The facility's policy requires that foods brought in from outside be stored in sealable containers, labeled, and dated, with refrigerated items discarded after 48 hours. These observations indicate a failure to adhere to the facility's food safety policies, potentially affecting all residents consuming food from the kitchen.
Deficiencies in Personal Care and ADLs for Residents
Penalty
Summary
The facility failed to provide adequate personal care for three residents, resulting in deficiencies in activities of daily living (ADLs). Resident R129, who has a diagnosis of Parkinsonism and requires assistance with ADLs, reported not receiving a shower for four weeks and had unwashed hair with white flakes. Despite being scheduled for showers twice a week, records showed R129 only received bed baths and one refusal. The resident's fingernails were also observed to be long and dirty. Staff cited a shortage of slings for mechanical lifts as a reason for not providing showers, although the resident did not refuse the care. Resident R61, diagnosed with hemiplegia and requiring assistance with ADLs, was observed with long chin hairs and reported not being shaved during bed baths. The resident expressed a preference for bed baths but did not prefer having long facial hair. The care plan indicated a need for substantial assistance with personal hygiene, which was not adequately provided. Resident R79, with diagnoses including Osteomyelitis and Chronic Obstructive Pulmonary Disease, reported excessively long toenails and could not recall seeing a podiatrist since admission. The Director of Nursing acknowledged the need for toenail trimming and stated that non-diabetic residents should have their toenails monitored and trimmed during ADL care. The facility's policy on ADLs and nail care emphasized regular grooming, which was not adhered to in these cases.
Failure to Document and Date PICC Line Dressings
Penalty
Summary
The facility failed to ensure proper documentation and care for PICC line dressings for two residents. For one resident, a rolled gauze dressing was observed on multiple occasions without a visible date or transparent dressing, and the insertion site was not visible. The LPN reported that the gauze dressing was used because the resident had previously pulled out the PICC line, and acknowledged that a transparent dressing should have been in place. The Unit Manager confirmed the absence of a date and transparent dressing. The resident's records showed no documentation of PICC line dressing changes, despite the administration of IV antibiotics being recorded. For the second resident, a transparent PICC line dressing was observed without a date. The Unit Manager confirmed the dressing should have been dated and noted that the resident's records lacked documentation of PICC line assessments or dressing changes since admission. An order for weekly dressing changes was entered by the infection control nurse on the day of observation. The Director of Nursing confirmed that PICC line dressings should be transparent, changed weekly, and dated, with assessments conducted when hanging each IV. The facility's policy outlined the procedure for dressing changes, which was not followed in these cases.
Deficiencies in Mechanical Lift Use and Smoking Policy Enforcement
Penalty
Summary
The facility failed to ensure the proper use and maintenance of a mechanical lift sling, leading to a fall and subsequent hospitalization of a resident. The resident, who had a history of cerebral infarction with left hemiplegia, muscle weakness, and anxiety disorder, fell from a mechanical lift due to a ripped sling. The incident occurred during a transfer from the bed to a lounger-chair, with only one CNA and a housekeeper present, contrary to the facility's policy requiring two trained staff members. The CNA did not inspect the sling before use, and the sling was found to be frayed and torn near the strap. Additionally, the facility failed to secure smoking and vape pens for residents, as observed with a resident who had a vape pen attached to a necklace and used it in their room, against the facility's smoking policy. The resident admitted to using the vape pen in their room due to delays in being assisted to the designated smoking area. The facility's policy prohibits smoking inside the building and requires smoking materials to be stored at the nursing station unless deemed safe by Resident Services. The facility's policies on safe lifting and smoking were not adhered to, resulting in unsafe conditions for residents. The mechanical lift policy mandates two staff members for transfers and regular equipment checks, while the smoking policy requires smoking materials to be kept at the nursing station and prohibits indoor smoking. These lapses in policy enforcement contributed to the deficiencies noted in the report.
Medication Storage Deficiency
Penalty
Summary
The facility failed to store medications securely and in accordance with professional principles for four residents. One resident was found with a white pill in a medication cup on their overbed table, and they were unsure how long it had been there. Another resident had an orange gel capsule in a medication cup on their window sill, which they did not take because they had a bowel movement and informed the nurse of their refusal. A third resident had a red inhaler on their overbed table and was unsure if it was supposed to be kept in their room. A fourth resident was found with a small plastic bag containing over 20 pills, which they stated they were not taking and did not need. This resident had a medical history of major depressive disorder, dementia with mood disturbance, and adjustment disorder with mixed anxiety and depressed mood. The Director of Nursing was shown the bag of pills and confirmed the facility's policy that medications should be taken with the nurse present, and any refused medications should be removed from the room. The facility's policy on medication storage emphasizes proper sanitation, temperature, light, ventilation, moisture control, segregation, and security.
Failure to Repair Malfunctioning Bed
Penalty
Summary
The facility failed to repair or replace a malfunctioning bed for a resident, identified as R136, who had been readmitted following a right above-knee amputation. The resident reported that the height adjustment of their bed had not worked since their admission, and despite informing multiple staff members, including maintenance and nursing staff, the issue was never addressed. During an observation, the resident demonstrated that while the head and foot adjustments worked, the height adjustment did not, producing a loud grinding noise instead. Interviews with facility staff, including a CNA and an LPN, revealed that they were aware of the bed's malfunction but had not reported it to maintenance. The Maintenance Director stated that they were unaware of the issue and that no work orders had been submitted regarding the bed. The Director of Nursing indicated that the expectation was for nursing staff to report such issues directly to maintenance or complete a work order. However, the facility administrator could not identify a policy addressing the reporting of malfunctioning equipment.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Warren
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Orchards At Warren | 0.4 mi | — | 22 | 0 |
| Windemere Park Health And Rehabilitation Center | 1.5 mi | — | 2 | 0 |
| Harmony Village Of Warren | 2 mi | — | 0 | 0 |
| The Villa At City Center | 2 mi | — | 7 | 0 |
| Father Murray, A Villa Center | 2.2 mi | — | 5 | 0 |
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