Above average — CMS composite of the measures below.
The next survey window likely opens around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Autumn Lake Healthcare At The Willows during CMS and state inspections, most recent first.
Ophthalmic medications were found open on multiple med carts without documented opening dates. During cart inspections, several eye drops including brimonidine, latanoprost, timolol, dorzolamide/timolol, ciprofloxin, Systane, and Refresh were observed undated. The Pharmacy Consultant and DNS both stated eye drops should be dated after opening per facility policy.
Failure to document and track flu and pneumococcal vaccinations affected 4 of 5 residents reviewed. One resident had pneumococcal vaccine administration documented without a signed consent, another had no record that influenza vaccine was offered, and two residents had consent documented but no record that the vaccines were actually administered. The IP stated she relied only on clinical records and had no tracking system for resident vaccination status.
A resident with DM2, neuropathy, venous insufficiency, and dementia had bilateral unstageable heel pressure injuries and required heel boots, kerlix wrapping, and other off-loading measures. Staff observed the resident in bed without the ordered boots or other effective heel off-loading, and a pillow at the foot of the bed was not being used. Interviews showed staff knew the resident often removed or refused the devices, but refusals were not consistently documented or communicated, and no alternative off-loading methods were attempted during the observed period.
Tube feeding was not provided according to ordered precautions for a resident with Parkinson's disease, dysphagia, and a G-tube. The resident was observed receiving Jevity while nearly flat in bed, and an LPN confirmed the HOB should have been elevated 30 to 45 degrees during infusion. The care plan did not reflect the feeding tube, and an NA stated she did not know the feeding should be paused while the resident was flat during care.
Failure to act on a dialysis-related med recommendation for a resident with ESRD, schizoaffective disorder, and multiple myeloma. The specialized treatment center recommended decreasing Sevelamer Carbon 800 mg from 2 tabs to 1 tab TID with meals, but the order was not changed in the MAR/physician orders. Interviews confirmed the recommendation was communicated to the facility, but it was not placed in the APRN review process and the APRN was unaware of it.
Failure to arrange an oral surgery consult for a resident with prostate and bone CA, anxiety, and depression. The in-house dentist documented that extractions were needed and could not be done on site, and broken teeth were observed, but the resident had not been scheduled with an oral surgeon despite orders and NP notes reflecting the referral.
Meals Served Below Required Hot Food Temperature: A resident reported that food was cold at times, and a test tray observation found hot items served below the required temperature. The lunch meal was transported from the kitchen in an enclosed cart and served efficiently, but the pork entree and cooked carrots were below 135 degrees F when checked, while the Dietary Manager stated hot foods should be no less than 135 degrees F and the facility policy and service line checklist required the same.
Ophthalmic Medications Left Undated After Opening
Penalty
Summary
The facility failed to ensure ophthalmic medications were labeled properly after opening. During observation of 4 of 6 medication cart inspections, multiple open eye drop bottles were found with no documented dates showing when they were opened. On the 2nd floor long hall cart, open bottles of brimonidine tartrate 0.2% eye drops, Systane eye drops, and Refresh eye drops had no opening dates. On the 2nd floor short hall cart, open bottles of dorzolamide hydrochloride/timolol maleate 2%/0.5% eye drops, latanoprost 0.005% eye drops, brimonidine tartrate 0.2% eye drops, ciprofloxin 0.3% eye drops, and timolol 0.5% eye drops were observed without documented dates. On the private short hall cart, open bottles of brimonidine tartrate 0.2% eye drops, latanoprost 0.005% eye drops, and Refresh eye drops were also undated, and on the private long hall cart an open bottle of latanoprost 0.005% eye drops had no opening date. The Pharmacy Consultant stated ophthalmic medications should be dated according to facility policy, the DNS stated she would expect eye drops to be dated after opening according to policy, and the facility policy directed ophthalmic medications to be dated at the time of opening.
Failure to Document and Track Flu and Pneumococcal Vaccinations
Penalty
Summary
The facility failed to ensure informed consent and documentation of pneumococcal and influenza vaccinations were completed according to policy for 4 of 5 residents reviewed. One resident, who was self-responsible and had diagnoses including cerebral palsy and mitral insufficiency, had a pneumococcal vaccine administered, but the pneumococcal vaccine informed consent form did not contain a documented signed consent. Another resident, who was not self-responsible and had diagnoses including COPD and atherosclerotic heart disease, had no documentation in the clinical record that the influenza vaccine was offered to the resident or the responsible party in 2024. A third resident, who was not self-responsible and had diagnoses including atherosclerotic heart disease and type II diabetes, had a pneumococcal vaccine informed consent signed by the responsible party, but the clinical record did not show the vaccine was administered. A fourth resident, who was self-responsible and had a history of bronchitis, had consent documented for both pneumococcal and influenza vaccines, but the clinical record did not show either vaccine was administered and also had no documentation that the influenza vaccine was offered in 2024. The Infection Preventionist stated she relied solely on clinical records to monitor vaccination status, had not implemented a tracking system, and could not explain how resident vaccination status was monitored over time. The DNS stated immunizations should be offered on admission and annually as indicated, tracked over time, and remain up to date with documented refusals.
Failure to Maintain Heel Off-Loading for Resident With Bilateral Pressure Ulcers
Penalty
Summary
The facility failed to ensure appropriate pressure ulcer care and off-loading for a dependent resident with diabetes type 2 with diabetic neuropathy, venous insufficiency, and dementia. The resident’s admission assessment showed moderate cognitive impairment, maximal/substantial assistance needs for bed mobility and transfers, and a pressure ulcer present on admission. The care plan identified bilateral heel pressure injuries and directed use of off-loading heel boots, kerlix wrapping, socks, and other measures to prevent rubbing and friction, while later care plans noted the resident sometimes kicked off the multi-podus boots and staff were to re-approach if care was refused. The resident’s wound record showed bilateral unstageable heel ulcers with eschar, and the physician’s wound note documented ongoing heel wounds with orders for turning, repositioning, and heel off-loading. The September treatment record indicated the heel boots were in place or intermittently refused, but nursing notes did not document all refusals or the reasons for them. During intermittent observations, the resident was found lying in bed without heel off-loading, with a pillow at the end of the bed not in use and no boots on the feet. At one point the resident was boosted for breakfast while still positioned on the back, and staff did not place the pillow under the legs, did not apply the ordered boots, and did not offer any type of off-loading before leaving the room. Interviews showed staff knew the resident often refused or removed the boots and sometimes kicked away the pillow, but the charge nurse stated she had not been informed of refusals during the shift and the nurse aide stated she had not checked whether the heels were off-loaded. The charge nurse also could not locate documentation showing refusals of off-loading boots or pillows during August and September. The regional nurse stated other off-loading methods were available and should have been attempted, and that the resident should not have been left for 3 hours without off-loading attempts. The facility policy required repositioning, notifying supervision when a resident refused, and evaluating alternatives, but the resident remained without effective heel off-loading during the observations.
Tube Feeding Given With Head of Bed Flat
Penalty
Summary
Enteral feeding was not provided according to professional standards for Resident #65, who was admitted in January 2025 and readmitted in May 2025 after hospitalization. The resident had diagnoses including Parkinson's disease, dysphagia, and a gastrostomy tube. Physician orders for September 2025 directed Jevity 1.5 at 75 mg/hour for 16 hours, with the head of bed elevated 30 to 45 degrees during feeding and for 30 to 45 minutes afterward, and elevated for 60 minutes after medication administration via the feeding tube. The quarterly MDS identified intact cognition, fluctuating disorganized thinking, a feeding tube, and that 51% or more of total calories were received through the feeding tube. On 9/16/25, the care plan did not reflect the resident's feeding tube. During observation at 11:40 AM, the resident was in bed receiving tube feeding at 75 cc/hour with the head of bed less than 30 degrees, almost flat, and alone in the room. A later observation at 11:53 AM with LPN #12 found the resident flat in bed receiving tube feeding at 75 cc/hour while receiving care from NA #11. LPN #12 stated the head of bed was flat but should be up between 30 and 45 degrees while tube feeding was infusing, and then turned off the tube feeding. NA #11 stated she did not know the tube feeding should be paused while the resident was flat in bed receiving care. The facility then initiated staff training, and the policy provided did not address ensuring the head of bed is elevated when a resident is receiving tube feeding.
Failure to Act on Dialysis Medication Recommendation
Penalty
Summary
The facility failed to ensure that a recommendation from the specialized treatment center to change Sevelamer Carbon was acted upon for Resident #7, who had end stage renal disease, schizoaffective disorder, and multiple myeloma. The quarterly MDS identified the resident as cognitively intact and independent with bed mobility, dressing, and transfers. The care plan identified impaired renal function with risk for complications related to specialized treatments and included interventions to monitor lab values, report abnormal values to the physician, send the communication book to the specialized treatment center, and review it upon return. Review of the specialized treatment communication book showed a request to decrease Sevelamer Carbon 800 mg from 2 tablets to 1 tablet three times daily with meals. However, review of physician orders from 9/1/25 through 9/23/25 did not show the medication change. Interviews with the facility administrator, the specialized treatment center dietician, and RN #2 confirmed that the recommendation had been communicated to the facility and that the process was to place the recommendation in the APRN book for review and order approval, but the APRN had not been made aware of it. The APRN book did not contain the recommendation, and the facility used agency staff who may have set the communication book aside without reviewing it for recommendations.
Failure to Arrange Oral Surgery Consultation for Dental Extractions
Penalty
Summary
The facility failed to provide dental services for a resident who had been identified by the in-house dentist as needing evaluation by an oral surgeon for extractions that could not be treated on site. The resident’s diagnoses included prostate and bone cancer, anxiety, and depression. The comprehensive MDS identified the resident as cognitively intact, requiring substantial to maximal assistance with bed mobility, independent with eating, and needing set-up/clean-up assistance with oral hygiene, but it did not identify dental irregularities such as broken teeth. The care plan in effect also failed to identify the resident’s dental issues. The resident stated that he or she had been seen by the in-house dentist a few months earlier and was told that an oral surgeon outside the facility was needed. Two broken teeth were observed when the resident opened his or her mouth. Physician orders directed a referral to an oral surgeon, and dental consultation reports dated earlier in the year documented the need for oral surgery and noted that extractions had not been performed because the resident could not be treated on site. Nurse practitioner notes also documented that a referral to a dental oral surgeon for extraction consult was in place, yet the resident had not had an appointment scheduled since the dentist’s referral.
Meals Served Below Required Hot Food Temperature
Penalty
Summary
The facility failed to serve meals at a palatable temperature for Resident #43. Resident #43 had diagnoses including heart disease, emphysema, and chronic obstructive pulmonary disease, and the admission MDS identified the resident as cognitively intact, requiring set-up assistance for eating, partial moderate assistance for bathing, and substantial to maximal assistance for toileting and transfers. During interview, Resident #43 stated that the food was cold at times. During a test tray observation, the lunch meal was plated from a warming plate, placed in a blue-plate holder with a blue enclosed lid, and transported in an enclosed metal cart containing 7 to 8 meals. The last cart was transferred to the first-floor unit, trays were passed efficiently, and the last tray was served at 12:31 PM. At 12:32 PM, temperatures were taken and the pork entree measured 127 degrees F by the surveyor and 129 degrees F by the Dietary Manager, the beef measured 135 degrees F by both thermometers, and the cooked carrots measured 119 degrees F by the surveyor and 122.5 degrees F by the Dietary Manager. The Dietary Manager stated hot food items should be no less than 135 degrees, and the service line checklist and Food Quality and Palatability policy also identified hot foods should be 135 degrees or higher.
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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 Woodbridge
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Grimes Center | 3.1 mi | ★★★★★ | 13 | 0 |
| Whitney Center | 3.3 mi | ★★★★★ | 0 | 0 |
| Advanced Center For Nursing & Rehabilitation | 3.6 mi | ★★★★★ | 20 | 1 |
| Arden Care Center | 4 mi | ★★★★★ | 28 | 0 |
| West Haven Center For Nursing & Rehabilitation | 4.1 mi | ★★★★★ | 2 | 0 |
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