Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
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 View Health Care Facility L L C during CMS and state inspections, most recent first.
A resident with cervical cancer, rheumatoid arthritis, and multiple pressure ulcers was readmitted with several stage 3, stage 4, and unstageable wounds already present. Facility policy required a full skin and wound assessment on admission, including staging, measurements, and detailed descriptions. An RN completed the admission evaluation but only documented general wound locations and approximate sizes, without staging or precise measurements, and did not seek assistance despite reporting a lack of training in wound measurement and staging. Nursing notes and weekly skin documentation for several days after readmission contained no full wound assessment, and the first complete staging and measurement of all pressure ulcers was not recorded until a wound care consultant visit, contrary to expectations from the MD, ADON, and DON that such assessments be completed within 24 hours of admission/readmission.
Smoking Materials Not Kept Per Care Plan: A resident with dementia and severe cognitive impairment had a care plan directing that smoking materials be kept at the nurse’s station, yet staff observed the resident with cigarettes in a pouch and later found 22 cigarettes in the pouch when the resident returned from smoking. Interviews showed staff were giving the resident cigarettes and a lighter before smoking, while the SW, LPNs, DON, and Administrator described the expectation that the smoking materials be locked up and not in the resident’s possession.
Delayed Complete Assessment and Staging of Pressure Ulcers on Readmission
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely and complete assessment of pressure ulcers for a resident readmitted with multiple existing wounds. Facility policy required that all skin surfaces be inspected on admission, that risk factors be documented on the Skin Risk Data Collection Tool upon admission or change in condition, and that the Assistant Director of Nursing or designee initiate a weekly skin status evaluation when a pressure ulcer or chronic wound was identified. The policy also required that wound assessments include type, site, stage, size (length, width, depth in centimeters), description/characteristics, and treatment. The Admission Nursing Evaluation policy required compilation of physical and skin status information upon admission to determine care needs and further assessment. Resident #258 had significant medical conditions including cervical cancer, rheumatoid arthritis, and a vesicovaginal fistula, and was documented on the Minimum Data Set as cognitively intact, requiring substantial/maximal assistance for bed mobility, and having multiple pressure ulcers present on admission/readmission (one stage 3, one stage 4, and three unstageable ulcers). The comprehensive care plan identified impaired skin integrity and included interventions such as administering preventive treatments per provider order, monitoring skin daily during care, protecting skin with pressure reduction devices, and evaluating and measuring skin/wound sites at least weekly with documentation of outcomes and treatment progress. However, the Nursing Admission Evaluation completed by Registered Nurse #2 on the readmission date only described general wound locations and approximate sizes for some areas (e.g., buttock ulcer “stage to be determined,” small open areas on thigh and calf, heel and ankle wounds) and did not include staging or precise measurements for the pressure ulcers. Review of nursing progress notes, weekly skin status documentation, and medical visit notes from the date of readmission through several days afterward showed no evidence that a full pressure ulcer assessment, including measurements and staging, was completed during that period. The Medical Director’s note shortly after readmission referenced a chronic stage 4 sacral ulcer and directed readers to nursing notes for full assessments and measurements, but such documentation was not found. A complete wound assessment with staging and measurements was not documented until the Wound Care Consultant’s evaluation several days later, which detailed extensive stage 4 sacral/coccyx/bilateral gluteal fold ulcers and additional unstageable and stage 3 ulcers with specific dimensions. Interviews with an LPN, RN #2, the Medical Director, the Assistant DON, and the DON confirmed that facility expectations and practice were that an RN should complete full wound staging and measurements within 24 hours of admission/readmission, that RN #2 did not document stages or measurements and reported not being trained to do so, and that no one was contacted for guidance despite this lack of comfort, resulting in a delay in obtaining the required full assessment.
Smoking Materials Not Kept Per Care Plan
Penalty
Summary
Resident #222’s care plan was not followed as written regarding smoking materials. The resident had diagnoses including disorder of the brain, dementia, and hypertension, and the MDS documented severe cognitive impairment and that the resident was a smoker. The comprehensive care plan dated 03/03/2023 documented that the resident used tobacco products, and an intervention added on 05/23/2025 stated that smoking materials were to be kept at the nurse’s station. The Kardex dated 03/13/2026 also stated that smoking materials were to be kept at the nurse’s station and that the resident may go out on their own. During observation on 03/12/2026, the resident was in their room and stated they went outside to smoke. The resident lifted a pouch beside them in the wheelchair and a cigarette was found underneath it; when the pouch was opened, numerous cigarettes were found inside. The resident stated they did not have their lighter. On 03/13/2026, the resident was again observed returning from smoking and gave an LPN their lighter, and when the resident opened the pouch in the presence of the LPN, 22 cigarettes were found inside. The LPN stated they were unaware the resident had that many cigarettes and would lock them up. Staff interviews showed inconsistent understanding and implementation of the smoking plan. CNAs stated the resident’s cigarettes and lighter were kept at the nurse’s station, and nurses gave the resident one or two cigarettes and the lighter before going outside. The SW stated the resident was evaluated quarterly and that the resident had been determined safe to smoke, but also stated there had been times the resident appeared more confused than usual and that was why the smoking materials were to be kept at the nurse’s station. The DON and Administrator stated staff were expected to follow the care plan and not find smoking materials in the resident’s possession, but the resident was observed with cigarettes in their pouch despite the documented restriction.
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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 Hamburg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Elderwood At Hamburg | 0.4 mi | ★★★★★ | 3 | 0 |
| Father Baker Manor | 4.2 mi | ★★★★★ | 1 | 1 |
| Fox Run At Orchard Park | 5.1 mi | ★★★★★ | 0 | 0 |
| Eden Rehabilitation Nursing Center | 6 mi | ★★★★★ | 3 | 0 |
| Mercy Hospital Skilled Nursing Facility | 6.5 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.