Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Autumn Court during CMS and state inspections, most recent first.
A resident with dysphagia and a chopped meat diet order choked after being served a large piece of chicken that was not prepared to the ordered texture. Staff attempted the Heimlich maneuver, back blows, and CPR before EMS removed the chicken from the airway. The resident was hospitalized in critical condition, later required intubation and a G-tube, and speech therapy recommended NPO.
The facility's dishwasher failed to meet the manufacturer's temperature guidelines, with observed wash and rinse temperatures significantly below the required 120 degrees F. The Dietary Director confirmed the discrepancy, noting the machine was operating at lower temperatures than specified, potentially affecting all 48 residents receiving food from the kitchen.
The facility failed to maintain comfortable temperatures, affecting 18 residents, with room temperatures below the policy range of 71-81°F. Residents reported feeling cold, and the air conditioning was still on. Additionally, the facility did not maintain a clean environment, with a resident's privacy curtain stained with dried feces and another room having excessive spider webs. Staff acknowledged these issues, which violated the facility's cleaning policies.
An LPN at a facility failed to lock a medication cart after preparing medication, leaving it unattended for about two minutes. The cart was positioned near the dining room, with the LPN seated ten feet away and unable to see if residents approached the unlocked drawers. The facility's policy requires carts to be locked when unattended, especially given the residents' cognitive and behavioral health concerns.
A facility failed to properly prepare pureed foods for a resident requiring a pureed diet. Observations revealed that the pureed beef pot roast contained small pieces of ground beef, and the vegetable blend was a thin soup with large vegetable pieces. The Dietary Director confirmed the improper texture, despite previous concerns raised by the Speech Therapist about food texture modifications.
An LPN was observed touching oral medications with bare hands during preparation for two residents, contrary to the facility's policy. The DON confirmed that nurses should not touch medications with bare hands.
The facility did not provide required behavioral health training to newly hired STNAs, as confirmed by personnel file reviews and an HRD interview. The facility specializes in mental health behaviors, making this training essential.
Choking After Receiving Food Not Prepared to Ordered Texture
Penalty
Summary
The facility failed to ensure that a resident with a physician-ordered chopped meat diet received food prepared in the ordered texture. The resident had diagnoses including Parkinson’s disease, dementia, schizoaffective disorder, chronic kidney disease, heart failure, diabetes, and oropharyngeal dysphagia. The resident’s care plan and nutrition documentation showed the resident required supervision with eating and was ordered a mechanically altered diet with chopped meats, thin liquids, and other dietary restrictions. During the dinner meal in the dining room, the resident was under CNA supervision when the resident began choking after consuming a large piece of chicken that was not prepared according to the ordered chopped meat texture. Staff attempted the Heimlich maneuver and back blows, but the resident became unresponsive. Staff then moved the resident, initiated CPR, and called 911. EMS later removed a large piece of chicken from the resident’s trachea during airway management. Witness statements and interviews indicated the resident had a whole piece of chicken on the tray after the incident, while the ordered diet required chopped meat pieces no larger than one-half inch. The resident was transported to the hospital in critical condition with choking, hypoxemia, and unresponsiveness. Hospital records showed the resident required intubation, remained unresponsive, and later required a G-tube placement. Speech therapy evaluations later recommended the resident remain NPO. The report also noted that the facility had other residents on mechanically altered diets, and that the meal ticket for this resident did not identify the dinner selection or what meal was actually served.
Dishwasher Temperature Non-Compliance
Penalty
Summary
The facility failed to ensure that the dishwasher used for washing and rinsing dishes met the temperature requirements specified by the manufacturer's guidelines. During an observation, it was noted that the dishwasher, which was labeled with operational requirements, was supposed to have a minimum wash and rinse temperature of 120 degrees Fahrenheit. However, the temperatures recorded during the observation were significantly lower, with a wash temperature of 80 degrees F and a rinse temperature of 88 degrees F. Further cycles showed wash temperatures peaking at 88 degrees F and rinse temperatures at 95 degrees F. The Dietary Director (DD) confirmed that the dishwasher was a low-temperature machine and should operate at approximately 100 degrees F for washing and 110 degrees F for rinsing, which was contrary to the manufacturer's posted guidelines. Interviews and reviews of the Dish Machine temperature logs for August and September 2024 revealed that the dishwasher temperatures were consistently documented at 100 degrees F for washing and 110 degrees F for rinsing, except for a few instances where temperatures were even lower. The DD acknowledged the discrepancy between the recorded temperatures and the manufacturer's guidelines, indicating a failure to adhere to the specified temperature requirements. This deficiency had the potential to affect all 48 residents who received food from the kitchen, as the facility census was 48 at the time of the survey.
Temperature and Cleanliness Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain a comfortable temperature throughout the building, affecting 18 residents. Observations and interviews revealed that several rooms had temperatures ranging from 60 to 69 degrees Fahrenheit, which is below the facility's policy of maintaining temperatures between 71 and 81 degrees Fahrenheit. Residents reported feeling cold, with one resident wearing a winter coat indoors. The Maintenance Director confirmed that the air conditioning was still on, contributing to the low temperatures. Additionally, the facility did not maintain a clean and sanitary environment, affecting three residents. One resident's privacy curtain had a noticeable dried feces stain that remained unaddressed for over a day, despite staff acknowledging the need for it to be changed. Another room shared by two residents had excessive spider webs and debris, which was confirmed by the Regional Director of Clinical and the Director of Nursing. The facility's policies require routine cleaning and the changing of visibly dirty curtains to prevent infection transmission.
Medication Cart Security Lapse
Penalty
Summary
The facility failed to ensure the medication cart was secured at all times when unattended, which had the potential to affect all residents except three. During an observation, an LPN prepared medication at a cart parked near the dining room, with the drawers facing away from the seating area. After preparing medication for a resident, the LPN did not lock the cart and walked away to sit next to the resident at a table, approximately ten feet away from the cart. The nurse was focused on the resident and was unable to see if a resident in a wheelchair approached the unlocked drawers due to the cart's position and a half wall. An interview with the LPN confirmed that the cart was left unlocked and unattended for about two minutes, despite the facility's population of residents with cognitive, mental, and behavioral health concerns. The Director of Nursing confirmed that medication carts should be locked when out of sight or unattended. A review of the facility's policy on the Medication Dispensing System revealed that medication carts are to always be locked when out of sight or unattended.
Improper Preparation of Pureed Foods
Penalty
Summary
The facility failed to ensure that pureed foods were prepared properly for a resident who required a pureed diet. During an observation, the Dietary Director (DD) guided a staff member in preparing a pureed portion of the noon meal, which included beef pot roast and a vegetable blend. However, the pureed beef pot roast was observed to be a thick liquid with small pieces of ground beef, and the vegetable blend appeared as a thin soup with large pieces of vegetables. This improper preparation was confirmed when the resident received her meal, and the DD acknowledged that the vegetables were not blended to a pureed texture. The Speech Therapist (ST) had previously identified concerns with the facility's modified food textures, including pureed and mechanical soft diets, and had communicated these concerns to the facility. Despite this, the pureed pot roast provided to the resident was not smooth in texture, as confirmed by a follow-up interview with the DD. The production recipes for both the vegetable blend and beef pot roast indicated that the items should be processed until smooth, which was not adhered to in this instance.
Inappropriate Hand Hygiene During Medication Administration
Penalty
Summary
The facility failed to adhere to appropriate hand hygiene practices during medication administration, affecting two residents. On the morning of October 16, 2024, an LPN was observed preparing oral medications for two residents by touching the tablets with bare skin while removing them from their packaging and placing them into medication cups. This occurred for 13 medications for one resident and six medications for another. The LPN confirmed the actions during an interview immediately following the observations. The Director of Nursing later confirmed that nurses were instructed not to touch medications with bare hands, as per the facility's undated Medication Dispensing System policy.
Lack of Behavioral Health Training for New STNAs
Penalty
Summary
The facility failed to ensure that newly hired State tested Nurse Aides (STNAs) received the required specialty behavioral training. This deficiency was identified through a review of personnel files and staff interviews. Specifically, the personnel files for two STNAs, hired in August 2024, showed no evidence of training on mental health behaviors. An interview with the Human Resources Director confirmed that the facility did not provide formal specialized training for mental health behaviors to newly hired staff. The facility assessment indicated that the facility specializes in mental health behaviors, highlighting the importance of such training.
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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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| Meadows Of Ottawa The | 1.6 mi | ★★★★★ | 0 | 0 |
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| Willow Ridge Of Mennonite Home Communities Of Ohio | 11.3 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 August 2026) and official state health department websites.