Below average — CMS composite of the measures below.
The next survey window likely opens around March 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 Autumnwood Care Center during CMS and state inspections, most recent first.
The facility failed to ensure medications were administered as ordered when two residents did not receive multiple doses of their prescribed controlled medications due to reported unavailability, despite backup stock being present in the medication dispensing systems. One resident with anxiety and depression missed two scheduled doses of Ativan and became visibly distressed, shaking and tearful, while an LPN confirmed the omissions and the DON later acknowledged that Ativan tablets were available in backup stock. Another resident with a seizure disorder missed several scheduled doses of Phenobarbital after one dose was only partially available and subsequent doses were documented as unavailable and on order, even though the DON confirmed Phenobarbital tablets were present in the override cabinet. These events occurred despite facility policies requiring timely administration of medications as prescribed and advance reordering of controlled substances.
A facility failed to make state survey results available without asking staff and failed to post notice of their location in prominent, accessible areas. Residents, the receptionist, a CNA, the DON, and the Administrator all stated they were unaware of where the survey results were located, and observations of the lobby, nurses' stations, dining rooms, and hallways found no signage posted.
MDS assessments were inaccurately coded for three residents as requiring an invasive mechanical ventilator. Records showed AVAPS orders and respiratory diagnoses, but observations found the residents without tracheostomies or mechanical ventilators; one resident reported using CPAP at night instead. The MDS nurse stated AVAPS was being coded as invasive ventilator use, while the state RAI/OASIS educator stated AVAPS is non-invasive and most closely aligned with BiPAP.
Opened medications and biologicals were found improperly labeled on multiple medication carts and in the medication storage room. An LPN observed undated bottles of syrup, cough medicine, Milk of Magnesia, acetaminophen, Clear Lax, and tuberculin PPD, and also confirmed a resident’s Lantus pen had an open date recorded. Facility policy and manufacturer guidance reviewed during the survey required open dates on multi-dose products and noted shortened use periods for items such as insulin pens and tuberculin solution.
Unpalatable Meal Served at Improper Temperature: A test tray sent to the Memory Care unit included ravioli, green beans, a breadstick, and dessert. The ravioli and green beans were observed to be cold, and the ravioli lacked flavor while the green beans were unseasoned; an LPN and a resident both verified the items were not palatable and were cold when served.
Meal tray tickets for Memory Care residents did not include preferences, dislikes, or alternate food items, unlike tickets for other halls. The Dietary Manager said these residents were not asked what they wanted and received the meal as posted, and a CNA reported that certain food preferences for two residents were not honored even after staff told the kitchen.
Snacks Not Routinely Offered or Available: Residents reported that evening snacks were not offered, meals were too close together, and snacks were only provided if requested. CNAs stated they were responsible for passing snacks, but snack areas were observed empty and the Memory Care unit was rarely stocked. Facility policy required nourishing snacks between meals and routine evening snacks for all residents.
Improper food storage and use of non-pasteurized eggs were observed in the kitchen. Open and undated items were found in reach in freezer #1 and the walk in freezer, including sausage links, zucchini, biscuits, hash browns, Tator tots, chicken wings, garlic bread, chicken patties, waffles, lima beans, and onions. The DM verified the items were open and undated, and also verified that the eggs used in the facility were not pasteurized. Staff later observed preparing and serving over-easy eggs to a resident.
An effective pest control program was not maintained when mouse droppings were found in the Memory Care snack cabinet and a loaf of bread showed signs of chewing. An LPN confirmed there were about 42 droppings in the cabinet and was unsure how long they had been there or when the snacks were last served. Exterminator reports showed treatment in other areas of the facility, but not the Memory Care unit, despite the facility policy requiring the building to be kept free of insects and rodents.
The facility failed to notify a practitioner when ordered medications were unavailable for two cognitively intact residents with anxiety, depression, and seizure disorders. One resident with anxiety and depression had multiple scheduled doses of Ativan omitted because the drug was out of stock or awaiting pharmacy delivery, as documented on the MAR and in progress notes, and the NP later confirmed he had not been informed of these missed doses. Another resident with a seizure disorder missed several scheduled doses of Phenobarbital when only part of a dose was available and then the medication was not in stock, with the resident and an LPN confirming the omissions and the NP again stating he was not notified. These events occurred despite a facility policy requiring prompt physician notification when medications cannot be administered as ordered.
A resident with COPD and schizophrenia was observed placing a one-dose vial of Ipratropium-Albuterol into a nebulizer without nursing supervision, even though the resident had been assessed as unable to self-administer meds and had no order allowing self-administration. An LPN stated nursing provided the aerosol dose but allowed the resident to administer the treatment, and confirmed there was no self-administration order.
Failure to provide needed grooming care affected two residents who required staff assistance with ADLs. One resident with dementia and low cognition had long nasal hair protruding from his nostrils, and an LPN confirmed it needed trimming. Another resident with acute respiratory failure and PE had long fingernails extending beyond his fingertips; the resident said staff did not trim them and he often waited for his sister, while a CNA confirmed the nails needed trimming. The DON verified staff were required to complete ADL care even when hospice was involved.
A resident who was transferred to the hospital did not receive a required bed hold notice prior to or during the transfer. The resident, who was private pay and cognitively intact, only signed the bed hold agreement several days after returning, and reported not being informed about the policy or charges beforehand. Staff interviews confirmed the notice was delayed due to staff absence, contrary to facility policy requiring advance notification.
A resident with a history of hypokalemia received the wrong medication due to an incomplete verbal order and transcription error by the ADON. The LPN administered Kayexalate instead of potassium, leading to the resident's hospitalization for hypokalemia treatment. The facility lacked a policy for clarifying incomplete orders.
The facility failed to maintain kitchen sanitation and proper food storage, affecting 77 residents. The dishwasher did not reach the required 180°F for sanitization, and staff were unaware of the machine type. Soy sauce was improperly stored, a scoop was left in a cereal container, and an open box of omelets was found in the freezer. Facility policies on food storage and dishwasher use were not followed.
The facility failed to maintain the dishwashing machine in a safe operating condition, affecting 77 residents. The dishwasher, labeled as a high temperature machine, did not reach the required rinse temperature of 180°F. Despite attempts to fix the machine, it continued to provide inaccurate temperature readings, and the three sink system was not consistently used for sanitation. The facility's policy required immediate correction of inadequate temperatures, which was not effectively implemented.
The facility failed to maintain cleanliness in the laundry room, with lint accumulation behind industrial dryers, and did not address a long-standing brown stain on the ceiling in a resident room. The stain was due to a past leak, and although the leak was repaired, the ceiling was not repainted. These issues were confirmed by staff and residents.
A resident with intact cognition and multiple diagnoses was not provided showers as per their care plan, receiving bed baths instead due to the unavailability of a shower bed. The facility's DON was unaware of the issue, despite having two shower beds available. The facility's policy on Resident Rights was not upheld, as the resident's preference for showers was not honored.
A resident with intact cognition and multiple diagnoses, including diabetes and Parkinson's, did not receive quarterly statements for her personal funds, as required by the facility's policy. Despite authorizing the facility to manage her funds, there was no documentation of statements being provided, which was confirmed by both the resident and the Business Office Manager.
The facility failed to timely notify the physician and resident representative of a change in condition for two residents. A resident with multiple diagnoses reported ankle pain after an incident, but the physician and representative were not notified until weeks later, delaying an x-ray. The facility's policy required prompt notification, which was not followed.
A facility failed to maintain comfortable sound levels in the dining room on a secured unit due to sticky floors causing loud squeaking noises. This affected a resident with Alzheimer's and potentially impacted 12 others. Staff and resident interviews confirmed the noise was disruptive and agitating, with attempts to reduce it proving ineffective.
A facility failed to ensure a comprehensive care plan for a resident, who required compression stockings as per a physician's order. The care plan lacked goals or interventions for the stockings, and the resident reported them being too tight, informing several aides and nurses. The DON confirmed the care plan omission, contrary to the facility's policy for comprehensive, person-centered care plans.
A resident with multiple medical conditions, including lymphedema, was not provided with physician-ordered compression stockings due to them being too tight. Despite informing staff, the issue persisted, and the resident was observed without the stockings on multiple occasions. Staff interviews confirmed the oversight, and the DON was unaware of the problem.
A resident with multiple medical conditions, including dysphagia and moderate cognitive impairment, was not receiving tube feeding at the physician-ordered rate. Observations showed the feeding was set at incorrect rates on two occasions, with no justification documented. A nurse confirmed the error and adjusted the rate to the correct setting.
A resident was found with unsecured medications in their room, including Imodium and stomach chews, which they were using to manage diarrhea. The resident was not permitted to self-administer medications, and staff confirmed that all medications should be administered by a nurse. The facility's policy requires medications to be stored in locked compartments, which was not followed in this case.
A resident with multiple health conditions, including lymphedema, did not have physician-ordered compression stockings applied due to them being too tight. Despite the resident's refusal and communication of the issue to staff, the nursing staff falsely documented daily application in the Treatment Administration Record. The DON was unaware of the issue, and the facility's documentation policy was not followed.
The facility failed to maintain catheter bags in a sanitary manner for two residents, with one bag dragging on the floor and another improperly placed on a trash can. Additionally, a nurse administered medications to two residents using bare hands, violating infection control procedures. These actions were contrary to the facility's policies on catheter care and medication administration.
A resident with an implanted defibrillator experienced a deficiency in care when their cardiac transmitter device was misplaced during a room move and remained missing for several weeks. The facility lacked a policy for defibrillator monitor care, leading to inadequate monitoring and a delay in addressing the issue, which was only discovered during a cardiology appointment.
A resident with Alzheimer's and other health issues was transferred to a psychiatric facility without proper documentation or justification. The facility failed to provide a discharge notice, leaving the resident without a place to return. Interviews revealed inconsistencies in the reported behavior and the decision to transfer, with hospital staff describing the situation as patient dumping.
A resident with Alzheimer's and other conditions was transferred to a psychiatric facility without receiving the required discharge notice. The facility initially held the resident's bed but later refused re-admission without notifying the resident or their representative, leading to the resident remaining at the hospital.
A resident with Alzheimer's and other medical conditions was not allowed to return to the facility after a therapeutic leave to a psychiatric hospital, exceeding the bed-hold policy. Despite the resident's desire to return and lack of documented aggressive behavior, the facility did not provide a required discharge notice, leading to confusion and distress for the resident and family. Hospital staff perceived the situation as patient dumping.
Failure to Administer Ordered Controlled Medications Resulting in Missed Doses
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were free from significant medication errors and that medications were administered as ordered. One resident with COPD, anxiety disorder, major depressive disorder, asthma, suicidal ideations, and unspecified convulsions had an active care plan for anxiety that required medications to be administered as ordered and monitored for effectiveness. This resident had a physician’s order for Ativan 0.5 mg by mouth twice daily for anxiety and agitation. Review of the MAR showed that the evening dose on one day and the early dose the following day were not administered, with progress notes documenting that the Ativan was unavailable and on order, and that the facility was waiting on pharmacy delivery. During an interview and observation period, this resident reported that the facility had run out of her Ativan and she had not received her doses. She was observed shaking, tearful, visibly upset, and in emotional distress, and required staff intervention. An LPN confirmed the missed doses and the resident’s distressed condition. The DON later verified that nine tablets of Ativan were actually available in the facility’s backup medication dispensing machine and explained that staff only needed a physician order and a pharmacy code to obtain the medication. A nurse practitioner stated that missing two doses of Ativan can cause disruption in treatment and increase the resident’s anxiety. A second resident with diagnoses including convulsions, stage four chronic kidney disease, major depressive disorder, cerebral infarction, and seizures had an active care plan related to sedative/hypnotic therapy, with interventions to administer medications as ordered and monitor side effects and effectiveness every shift. This resident had physician orders for Phenobarbital 32.4 mg every morning and 129.6 mg every evening for seizures and convulsions. MAR review showed that one evening dose was only partially available and not fully administered, and subsequent evening and morning doses were not given because the medication was unavailable and on order. The resident reported not receiving Phenobarbital since a prior morning dose, and an LPN confirmed the missed doses. The DON verified that four tablets of Phenobarbital were available in the facility’s override medication dispensing cabinet. Facility policies required that medications be administered as prescribed, that controlled medications be requested when a minimum five-day supply remained, and that medications be administered safely, timely, and in accordance with prescriber orders.
Failure to Post and Make Survey Results Readily Available
Penalty
Summary
The facility failed to ensure state survey results were available without residents or visitors having to request them, and failed to post notice of the availability of those results in prominent and accessible areas. During interviews, residents #15, #19, #25, and #70 stated they were not aware of where the state survey results could be found. Observations of the front lobby, nurses' stations, dining rooms, and resident room hallways revealed no signage posted regarding the location of the state survey results. Staff interviews confirmed the same issue. The receptionist and a CNA both stated they were unaware of where the state survey results were located and unaware of any signage in the facility. The DON stated the survey results were usually kept in either the hallway or the dining room, but she was unaware of their current location and unaware of any signage. The Administrator verified the state survey results were not available in the facility without asking a staff member and also confirmed there was no signage posted regarding their location.
MDS assessments incorrectly coded AVAPS as invasive ventilator use
Penalty
Summary
The facility failed to ensure Minimum Data Set (MDS) assessments were accurately coded for three residents who were documented as requiring ventilator support. Resident #12 had diagnoses including paraplegia, COPD, obstructive sleep apnea, and dependence on a respirator. His quarterly MDS coded him as requiring an invasive mechanical ventilator, and his care plan described altered respiratory status and use of ventilator/AVAPS per orders. However, the physician order in the record described AVAPS AE settings with a face mask, and observation found him sitting in his room without a tracheostomy or respiratory ventilator, with an AVAP machine at bedside and a face mask attached. Resident #52 had diagnoses including COPD, dependence on respirator ventilator status, and obstructive sleep apnea. Her quarterly MDS also coded her as requiring an invasive mechanical ventilator. The medical record contained physician orders for ventilator/AVAPS AE settings and use for at least one hour during the shift, but observation found her ambulating in her room without a ventilator or tracheostomy. During interview, she stated she did not use a ventilator and instead used a CPAP machine while sleeping, which was observed at bedside. Resident #76 had diagnoses including COPD, obstructive apnea, acute and chronic respiratory status, and acute and chronic respiratory failure with hypoxia. His quarterly MDS was coded for an invasive mechanical ventilator, and his care plan described respirator/vent dependence and AVAP device use while sleeping. The record included physician orders for ventilator/AVAPS AE settings and use for at least one hour during the shift, but observation found him sitting in a wheelchair in the lounge napping without any mechanical ventilation. The MDS nurse stated the facility was coding AVAPS as invasive ventilator use because the physician used AVAPs, while the Ohio Department of Health RAI/OASIS Education Coordinator stated AVAPS is a non-invasive ventilation most closely aligned with BiPAP and should be coded as BiPAP when used during the look-back period.
Medications Found Opened Without Required Dates
Penalty
Summary
Medications and biologicals were not stored and labeled in accordance with accepted professional principles. During observation of the 300-hall medication storage cart, an opened 24-ounce bottle of chocolate syrup, an opened 16-ounce bottle of Geri-Tussin, and an opened 16-ounce bottle of Milk of Magnesia were found without open dates. In the same cart, a Lantus insulin pen labeled for Resident #37 was observed approximately one-half empty and marked as opened on 03/14/26; the LPN confirmed that insulin pens are only good for 28 days after opening if stored at room temperature and verified the pen’s open date. The facility census was 88. On the 100-hall medication cart, an opened 1000-tablet bottle of acetaminophen and an opened bottle of Clear Lax were observed without open dates, and an LPN verified both were opened and undated. In the medication storage room, a bottle of tuberculin purified protein derivative was also found approximately one-half full without an open date, and the LPN confirmed it was not labeled with one. Facility policies and manufacturer information reviewed during the survey stated that opened medications and multi-dose vials must be labeled with the date opened, and that certain products, including Lantus pens and tuberculin solution, have shortened use periods after opening.
Unpalatable Meal Served at Improper Temperature
Penalty
Summary
Food and drink were not provided in a palatable manner when a test tray prepared in the kitchen on 04/19/26 included ravioli in red sauce, green beans, a breadstick, and Jello poke cake. The tray was placed on the Memory Care meal cart at 12:14 P.M., left the kitchen at 12:16 P.M., arrived on the Memory Care unit at 12:18 P.M., and was fully passed to residents by 12:25 P.M. When the test tray was observed at 12:30 P.M., it had a colorful and appetizing appearance, but the ravioli was cold and lacked flavor, and the green beans were cold and unseasoned. The breadstick and Jello poke cake were flavorful. An LPN verified that the ravioli and green beans were not palatable. A resident also stated that the ravioli and green beans served that day were unpalatable and that the meal items were cold when received. Review of the facility policy titled Food and Nutrition Services, last revised October 2017, stated that food and nutrition staff will inspect food trays to ensure the correct meal is provided, the food appears palatable and attractive, and it is served at a safe and appetizing temperature.
Memory Care Meal Preferences Not Honored
Penalty
Summary
The facility failed to ensure that residents on the Memory Care unit had their meal preferences, dislikes, and alternate food choices identified and honored. During observation of meal tray preparation, meal tickets for residents on the 100, 200, 300, and 400 halls included the resident's name, diet order, allergies, preferences, dislikes, and alternate food items selected for the meal, but the Memory Care unit meal tickets only included the resident's name, diet order, and allergies. This affected 15 residents on the Memory Care unit who received food from the kitchen. During interview, the Dietary Manager stated the Memory Care unit residents were not asked about preferences because they were unable to determine what they wanted each meal, and that they received the meal as posted. A CNA stated that certain food preferences for two Memory Care residents were not honored and that kitchen staff had been told about those preferences but continued to send only the posted meal. Facility policy stated that individual food preferences would be assessed upon admission and communicated to the interdisciplinary team, and that food services would offer food choices and accommodate resident preferences.
Snacks Not Routinely Offered or Available
Penalty
Summary
Meals and snacks were not served at times in accordance with residents’ needs, preferences, and requests because snacks were not routinely available or offered. A resident stated dinner was served at 4:00 P.M. and no evening snacks were offered, leaving her hungry by breakfast. During a Resident Council meeting, multiple residents reported they had never been offered snacks, that evening snacks were not offered, or that they had to ask staff for a snack before one would be obtained. Staff interviews and observations showed the snack process was inconsistent. A CNA stated CNAs were responsible for passing snacks and that dietary staff were supposed to restock the coffee bars daily, but that did not always happen. Another CNA stated staff did not ask residents if they wanted snacks and only provided one if requested. Observations of the coffee bars on two halls found them empty with no snacks available, and a CNA stated the Memory Care unit was rarely stocked with snacks and residents there usually could not be provided snacks because they were not available. Facility policy stated nourishing snacks were to be available between meals and evening snacks were to be offered routinely to all residents.
Improper Food Storage and Use of Non-Pasteurized Eggs
Penalty
Summary
Food was not properly stored in the kitchen and freezer areas, and eggs served in the facility were not pasteurized. During observation on 04/19/26, reach in freezer #1 contained sausage links, zucchini, two bags of biscuits, hash browns, Tator tots, chicken wings, and garlic bread that were open and undated. The Dietary Manager verified that these items were open and undated. In the walk in refrigerator, the eggs used in the facility were observed not to be pasteurized, and the Dietary Manager verified this during the concurrent interview. In the walk in freezer, chicken patties and waffles were also observed open and undated.
Pest Control Program Failed to Address Mouse Activity in Memory Care Snack Area
Penalty
Summary
The facility failed to ensure effective pest control on the Memory Care unit. During observation of the Memory Care snack cabinet, mouse droppings were found on the shelves and at the bottom of the cabinet. A loaf of bread stored in the cabinet had a hole in the bag that appeared to be chewed through, and part of the loaf appeared to have small bite marks. An LPN verified there were approximately 42 mouse droppings in the cabinet and stated she was unsure how long they had been there or when the snacks in the cabinet were last given to residents. Review of exterminator reports showed treatment for rats and mice in public areas, common areas, and the south nurse's station after mice were sighted in the 600 hall and at the south nurse's station. A later pest control report documented routine service in multiple areas of the facility, but there was no evidence that the Memory Care unit had mice or was treated for mice. The facility policy titled Pest Control stated the facility shall maintain an effective pest control program to ensure the building is kept free of insects and rodents.
Failure to Notify Physician of Unavailable Ordered Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely physician notification when ordered medications were unavailable for two residents. For Resident #10, who was cognitively intact with a BIMS score of 15 and had diagnoses including COPD, anxiety disorder, major depressive disorder, asthma, suicidal ideations, and unspecified convulsions, the care plan required administration of anti-anxiety medications as ordered and monitoring for side effects and effectiveness every shift. The resident had a physician’s order for Ativan 0.5 mg by mouth twice daily for anxiety and agitation. The MAR showed that the evening dose on 04/18/26 and the morning dose on 04/19/26 were not administered, with documentation indicating the medication was unavailable and on order or awaiting pharmacy delivery. Resident #10 reported having anxiety and depression and stated that the facility had run out of her Ativan. An LPN confirmed that the resident did not receive the ordered doses on the evening of 04/18/26 and the morning of 04/19/26. The NP stated that missing two doses of Ativan can cause disruption in treatment and increase the resident’s anxiety and confirmed that he was not notified by the facility of the missed doses. The facility’s policy titled “Change in a Resident’s Condition or Status,” revised May 2024, required prompt physician notification of changes in condition, including inability to administer medications as ordered. For Resident #19, who was also cognitively intact with a BIMS score of 15 and had diagnoses including convulsions, anemia, stage four chronic kidney disease, major depressive disorder, syncope and collapse, tremor, cerebral infarction, and seizures, the care plan addressed sedative/hypnotic therapy related to convulsions/seizure disorder, with interventions to administer medications as ordered and monitor side effects and effectiveness every shift. The resident had orders for Phenobarbital 32.4 mg by mouth every morning and 129.6 mg in the evening for seizures and convulsions. The MAR showed that the evening doses on 04/17/26 and 04/18/26 and the morning dose on 04/18/26 were not administered, with progress notes documenting that only part of the dose was available on 04/17/26 and that the medication was not available and on order on 04/18/26. Resident #19 reported not receiving Phenobarbital since the morning of 04/17/26, and an LPN verified the missed doses. The NP confirmed that he was not notified of these missed doses, despite the facility’s policy requiring physician notification when medications cannot be administered as ordered.
Unsupervised Nebulizer Self-Administration Without Order
Penalty
Summary
The facility failed to ensure a resident who had been determined unable to self-administer medications did not self-administer nebulizer treatments. Resident #04 was admitted with diagnoses including acute renal failure, COPD, and schizophrenia. The resident’s MDS indicated cognitive function was intact, and the care plan noted schizophrenia affected the thought process and that medications were to be administered as ordered. The resident’s medication self-administration assessment showed the resident was not able to self-administer medication, and there was no order authorizing self-administration. Despite this, observation on 04/19/26 at 9:59 A.M. showed Resident #04 placing a one-dose vial of Ipratropium-Albuterol solution into the nebulizer without nursing supervision. The physician order for the medication directed it to be inhaled via nebulizer as needed for wheezing and shortness of breath and twice daily for cough and congestion, and a later order required staff to check lung sounds, pulse rate, and oxygen saturation before and after treatment and document setup and cleanup time. During interview, an LPN stated the resident was particular about the nebulizer treatment, so nursing provided the aerosol dose and allowed the resident to administer the treatment, and confirmed the resident did not have an order to self-administer medication.
Failure to Provide Needed Grooming Care
Penalty
Summary
The facility failed to ensure dependent residents received proper grooming, affecting two residents reviewed for ADL care. Resident #56 was admitted with diagnoses including Alzheimer's disease, dementia, suicidal ideations, anxiety, and amaurosis fugax. His MDS showed low cognitive function and a need for partial to moderate assistance with personal hygiene and showering, and his care plan directed moderate assistance from one staff member for personal hygiene and grooming tasks. Progress notes from 03/01/26 through 04/21/26 did not mention refusal of care, yet observation on 04/19/26 showed long nasal hair protruding about one-third of an inch outside his nostrils. An LPN confirmed the resident needed nose hair trimmed and stated the hair should have been trimmed on shower days. Resident #85 was admitted with acute respiratory failure and pulmonary embolism. His MDS showed he required substantial to maximum assistance for bathing and moderate assistance for personal hygiene, and his care plan identified a self-care deficit requiring staff assistance for grooming and personal hygiene. Observation on 04/20/26 showed his fingernails were long and extended about one-half inch beyond his fingertips. The resident stated he did not like having long nails, that staff failed to trim them, and that he usually had to wait for his sister to visit for nail care. A CNA confirmed the nails were long and needed trimming, and the DON verified facility staff were required to complete ADL care even when residents were also cared for by hospice staff. The facility policy stated residents unable to perform ADLs independently would receive services necessary to maintain good nutrition, grooming, and personal oral hygiene.
Failure to Provide Timely Bed Hold Notice to Resident During Hospital Transfer
Penalty
Summary
The facility failed to provide a required bed hold notice to a resident who was transferred to the hospital. The resident, who was private pay and cognitively intact, was sent to the emergency room after being found on the bathroom floor in pain. Documentation in the medical record confirmed the transfer and subsequent return from the hospital, but there was no evidence that the resident received a bed hold notice at the time of transfer. The bed hold notice was only signed by the resident several days after returning to the facility, and not prior to or during the hospital stay. Interviews with facility staff and the resident confirmed that the bed hold agreement was not discussed or signed before the hospital transfer. The social worker stated that the agreement was not obtained until after returning from time off, and the resident reported being unaware of the bed hold policy or any associated charges until after her return. Facility policy requires that residents and their representatives be informed of bed hold rights and payment policies prior to transfer, but this was not followed in this instance.
Medication Error Due to Incomplete Order
Penalty
Summary
The facility failed to ensure a medication order was complete and accurate, leading to a significant medication error involving Resident #10. The Assistant Director of Nursing (ADON) received a verbal order via text from a Certified Nurse Practitioner (CNP) to administer potassium to Resident #10 due to critically low potassium levels. However, the ADON misinterpreted the order and entered an incorrect medication order into the electronic medical record, resulting in the administration of sodium polystyrene sulfonate (Kayexalate), a medication used to remove potassium from the blood, instead of potassium replacement. The error was compounded when the Licensed Practical Nurse (LPN) administered the incorrect medication without verifying the laboratory results or questioning the order, despite being aware of the resident's history of hypokalemia and regular potassium supplementation. The LPN was informed by the ADON that the resident's potassium was high, which led to the administration of Kayexalate. Shortly after administration, the ADON realized the mistake, but it was too late to prevent the medication from being given. As a result of the medication error, Resident #10 experienced hypokalemia and required emergency hospital treatment, including oral and intravenous potassium replacement. The facility lacked a policy for clarifying incomplete orders from CNPs and physicians, contributing to the error. The deficiency was identified during a complaint investigation, highlighting the facility's failure to ensure residents are free from significant medication errors.
Kitchen Sanitation and Food Storage Deficiencies
Penalty
Summary
The facility failed to maintain the kitchen in a safe and sanitary manner, which had the potential to affect 77 residents. During an observation, it was found that the dishwasher, labeled as a high-temperature machine, was not reaching the required 180 degrees Fahrenheit for the rinse cycle. Instead, the highest temperature recorded was 154 degrees Fahrenheit. Dietary Staff #534 was unaware of the type of dishwasher being used, and the Dietary Director #601 confirmed the issue and instructed staff to use the three-sink system for sanitation. A review of the Dishwasher Temperature Record for December 2024 showed that the rinse temperature did not reach 180 degrees Fahrenheit on 20 out of 24 occasions. Additionally, the dry storage area was found to have a one-gallon bottle of soy sauce that was open and stored on a dry shelf, despite being labeled to refrigerate after opening. The Dietary Manager #601 verified this and disposed of the soy sauce. Further inspection revealed a scoop left inside a bulk rice puff cereal container, which should have been stored outside the container. In the reach-in freezer, an open box containing cheddar cheese omelets was found, with the Dietary Manager confirming that the box was left open and not in use. The facility's policies on food storage and dishwasher use were not adhered to, contributing to the deficiencies observed.
Dishwasher Temperature Deficiency
Penalty
Summary
The facility failed to maintain the dishwashing machine in a safe operating condition, which had the potential to affect 77 residents. The issue was identified when a dietary staff member was observed running dishes through the dishwasher without knowing whether it was a high temperature or chemical machine. The dishwasher was labeled as a high temperature machine, requiring a final rinse temperature of 180 degrees Fahrenheit. However, observations showed that the rinse temperature gauge did not move off the 100-degree mark, and an internal temperature gauge puck confirmed the highest temperature reached was only 154 degrees Fahrenheit. Further investigation revealed that the dishwasher had been experiencing issues with temperature gauges for a couple of months. Although the facility had been using a puck to ensure proper temperatures, they stopped using it after the gauges were reportedly repaired at the end of November. However, the dishwasher continued to fail to reach the required rinse temperature, and the three sink system was not utilized from December 1 to December 9, despite the temperature logs showing multiple instances where the dishwasher did not reach the proper rinse temperature. Subsequent observations and interviews confirmed that the dishwasher's temperature gauge was providing inaccurate readings, indicating higher temperatures than what was actually achieved. Despite attempts to fix the machine, the dishwasher continued to fail to reach the necessary rinse temperature of 180 degrees Fahrenheit. The facility's policy required that inadequate temperatures be reported and corrected immediately, but this was not effectively implemented, leading to the deficiency.
Facility Maintenance Deficiencies in Laundry and Resident Room
Penalty
Summary
The facility failed to ensure the dryers in the laundry room were cleaned appropriately, as observed on 12/10/24, when the walk-in vent area behind the facility's three industrial dryers was found covered in lint. Laundry staff confirmed that the Maintenance Supervisor only cleaned the lint once per year, which could potentially affect all residents in the facility. Additionally, the facility did not maintain a well-kept environment for two residents. In the room shared by these residents, a large brown stain was observed on the ceiling above one of the beds. The residents confirmed the stain had been present for a long time, and although they made light of it by imagining shapes, they expressed a desire for the ceiling to be painted. The Maintenance Supervisor acknowledged the stain, attributing it to a past leak that had been repaired, though he could not recall when the repair occurred.
Failure to Honor Resident's Shower Preferences
Penalty
Summary
The facility failed to honor a resident's shower preferences, affecting a resident with intact cognition and multiple diagnoses, including bipolar disorder and diabetes. The resident's care plan specified a preference for showers three times a week, but documentation from 10/12/24 to 12/11/24 showed no record of showers being provided, only bed baths. Interviews with the resident and CNAs confirmed that the resident was not receiving showers as preferred, with CNAs citing the unavailability of a shower bed as the reason. The Director of Nursing was unaware of the issue and revealed that the facility had two shower beds available, contradicting the CNAs' statements. The facility had recently implemented shower sheets to track whether residents received showers or baths, but there were no records for the resident from 10/12/24 to 11/29/24. The facility's policy on Resident Rights, revised in 2016, states that residents have the right to participate in decision-making regarding their care, which was not upheld in this case.
Failure to Provide Quarterly Personal Fund Statements
Penalty
Summary
The facility failed to provide quarterly statements for personal funds to a resident, which is a requirement as per their policy. The deficiency was identified during a review of the medical record, staff and resident interviews, and policy review. The affected resident, admitted on 09/11/17, had diagnoses including type two diabetes mellitus, bipolar disorder, Parkinson's disease, and hypertension, and was noted to have intact cognition according to a recent MDS assessment. The resident had authorized the facility to manage her personal fund account, but there was no documentation that she received quarterly statements. During an interview, the resident confirmed that she had not been provided with a copy of her quarterly statement in the past year. The Business Office Manager verified the absence of documentation for the quarterly statements, which is contrary to the facility's policy revised in 04/2017.
Failure to Timely Notify Physician and Representative of Resident's Condition Change
Penalty
Summary
The facility failed to timely notify the physician and resident representative of a change in condition for two residents. Resident #30, who had diagnoses including chronic obstructive pulmonary disease, heart failure, dementia, and anxiety, reported pain in her right ankle and foot after moving it wrong in the middle of the night. Despite the resident's complaint of pain and request for an x-ray, there was no documentation that the physician or resident's representative were notified at the time of the incident on 11/17/24. The nurse's note indicated that the resident had wrapped her own foot with an elastic bandage, and the nurse provided a leg pedal for the wheelchair but did not notify the physician or representative. It was not until 12/09/24 that the physician was notified, and an x-ray was ordered, which revealed no fracture or acute disease. The Director of Nursing confirmed the lack of timely notification and the delay in obtaining an x-ray. The facility's policy, revised in 05/2017, required prompt notification of changes in a resident's condition to the resident, attending physician, and representative, which was not adhered to in this case.
Disruptive Noise Levels in Dining Room Due to Sticky Floors
Penalty
Summary
The facility failed to maintain comfortable sound levels in the dining room on the secured unit, affecting one resident and potentially impacting 12 others. The issue was identified through observations and interviews with staff and residents. The floors in the dining room were clean but sticky, causing loud squeaking noises as staff and residents walked across them. This noise was disruptive and agitating to the residents, particularly those with cognitive impairments. Resident #59, who has Alzheimer's disease, anxiety disorder, muscle weakness, and dementia, was notably affected by the noise. The resident, who is moderately cognitively impaired and requires assistance with daily activities, expressed that the squeaking noises were very noisy and bothersome. Staff interviews confirmed that the noise was a regular occurrence and that attempts to reduce it, such as mopping the floors or walking outside in the rain, were ineffective.
Incomplete Care Plan for Compression Stockings
Penalty
Summary
The facility failed to ensure a comprehensive care plan was complete and current for a resident, affecting one of two residents reviewed for comprehensive care planning. The resident, who was admitted with diagnoses including bipolar disorder, chronic obstructive pulmonary disease, chronic respiratory failure, ataxia, Parkinson's, schizoaffective disorder, and lymphedema, required maximum assistance for lower body dressing and oxygen therapy. A physician's order was in place for compression stockings to be applied in the morning and removed at bedtime. However, the care plan did not include goals or interventions for the use of these stockings. An observation revealed that the resident did not have the compression stockings applied, and during an interview, the resident stated that the stockings were too tight and had informed several aides and nurses about this issue. The Director of Nursing confirmed that the care plan failed to include information about the compression stockings. The facility's policy required a comprehensive, person-centered care plan with measurable objectives and timetables to meet the resident's needs, which was not implemented in this case.
Failure to Provide Physician-Ordered Compression Stockings
Penalty
Summary
The facility failed to provide a resident with compression stockings as ordered by the physician. The resident, who had a medical history including bipolar disorder, chronic obstructive pulmonary disease, chronic respiratory failure, ataxia, Parkinson's, schizoaffective disorder, and lymphedema, was observed without the prescribed compression stockings on two separate occasions. The resident required maximum assistance for lower body dressing and was on oxygen therapy. The care plan included monitoring for lower extremity swelling, and there was a physician's order for compression stockings to be applied in the morning and removed at bedtime. Despite the physician's order, the resident did not have the compression stockings applied because they were too tight, as reported by the resident. The resident had informed several aides and nurses about the issue, but the problem persisted. Interviews with staff, including an LPN and the DON, confirmed the oversight, with the DON being unaware of the resident's inability to wear the stockings. The deficiency was identified through observations and interviews, highlighting a lapse in following the physician's orders and addressing the resident's needs.
Failure to Administer Tube Feeding at Ordered Rate
Penalty
Summary
The facility failed to ensure that a resident's tube feeding was administered at the physician-ordered rate. The resident, who was moderately cognitively impaired and required maximal assistance with daily activities, had a medical history that included Parkinson's Disease, dysphagia, and moderate protein calorie malnutrition. The resident's care plan indicated that they were on a no food by mouth (NPO) status and received more than half of their total calories through tube feeding. The physician's order specified that the resident should receive 55 ml of Nepro Carb Steady oral liquid supplement via gastrostomy tube every shift, with a water flush of 240 ml every four hours. Observations on two consecutive days revealed that the resident's tube feeding was running at rates of 59 ml per hour and 50 ml per hour, rather than the ordered 55 ml per hour. There was no documentation or justification for these deviations from the prescribed rate in the resident's progress notes or electronic Medication Administration Record (eMAR). A registered nurse confirmed that the tube feeding was set incorrectly and adjusted it to the correct rate. The facility's policy on enteral nutrition, revised in November 2018, stated that adequate nutritional support should be provided as ordered, which was not adhered to in this instance.
Resident Medications Found Unsecured in Room
Penalty
Summary
The facility failed to ensure that resident medications were kept secured, affecting one resident. The resident, who was cognitively intact and required maximal assistance with daily activities, was found to have a blister pack of white pills and loose multicolored tablets in a baggie in the drawer of his overbed table. The resident confirmed that he was keeping Imodium and stomach chews at his bedside to manage his diarrhea, despite not having permission to self-administer medications. Interviews with facility staff, including a CNA and an RN, confirmed that the resident was not permitted to self-administer medications and that all medications should be administered by a nurse. The RN observed and removed the unsecured medications from the resident's room, acknowledging the breach in protocol. The facility's policy on medication storage, which requires all drugs and biologicals to be stored in locked compartments, was not adhered to in this instance.
Failure to Accurately Document Compression Stocking Application
Penalty
Summary
The facility failed to ensure accurate documentation regarding the application of compression stockings for a resident diagnosed with multiple conditions, including lymphedema. The resident, who required maximum assistance for lower body dressing, had a physician's order for compression stockings to be applied in the morning and removed at bedtime. However, observations revealed that the resident did not have the stockings applied, and the resident reported that the stockings were too tight and had not been worn for months. Despite this, the nursing staff documented in the Treatment Administration Record (TAR) that the stockings were applied daily. Interviews with the resident and staff confirmed that the compression stockings were not applied as ordered. The resident had informed several aides and nurses about the issue, but no new stockings were provided. The Director of Nursing was unaware of the situation and verified that the staff had falsely documented the application of the stockings. The facility's policy on charting and documentation requires that medical records be objective, complete, and accurate, which was not adhered to in this case.
Infection Control and Medication Administration Deficiencies
Penalty
Summary
The facility failed to maintain catheter collection bags in a safe and sanitary manner for two residents with indwelling catheters. Resident #39's catheter bag was observed dragging on the floor as a CNA pushed her wheelchair to the dining room. The CNA was unaware of the issue until it was pointed out, acknowledging it as an infection control problem. Similarly, Resident #56's catheter bag was found hanging on the side of a trash can and partially touching the floor, with the privacy bag cover being rolled over by a bedside table wheel. Despite being aware of the improper placement, staff did not consistently reposition the bag to prevent contact with the floor. The facility also failed to ensure medications were administered in a sanitary manner. During medication administration, RN #545 was observed handling medications for Resident #56 and Resident #69 with bare hands, contrary to the facility's infection control procedures. The nurse admitted to directly touching the medications without gloves, and the Director of Nursing confirmed that this practice was against policy. The facility's policies on urinary catheter care and medication administration were not adequately followed, leading to these deficiencies. The urinary catheter care policy did not explicitly state the requirement to keep catheter bags off the floor, while the medication administration policy required adherence to infection control procedures, which were not followed by the staff.
Failure to Monitor Cardiac Defibrillator
Penalty
Summary
The facility failed to adequately monitor the placement of a resident's cardiac defibrillator external heart monitor, affecting a resident with congestive heart failure, coronary artery disease, atrial fibrillation, and an implanted defibrillator. The resident had a moderately impaired cognitive level and required maximum assistance for transfers. The resident's care plan required monitoring of the implanted defibrillator to ensure the resident remained free from signs and symptoms of pacemaker malfunction or failure. However, during a room move, the resident's cardiac transmitter device was misplaced and not discovered until a cardiology appointment revealed the resident had been defibrillated due to ventricular tachycardia. The facility did not have a policy related to the care of defibrillator monitors, and the monitor was missing for at least four weeks. During this time, the facility was unable to connect the transmitter device to the internet, requiring an adaptor to be ordered. The issue was identified when the resident's cardiologist noted the defibrillator had successfully defibrillated the resident without their awareness. The facility's failure to monitor the defibrillator device and ensure it was properly connected led to the deficiency.
Failure to Provide Adequate Documentation and Justification for Resident Transfer and Discharge
Penalty
Summary
The facility failed to provide the required documentation and justification for the transfer and discharge of a resident, identified as Resident #76, to a hospital. The resident, who had a history of Alzheimer's disease, spinal stenosis, congestive heart failure, and ischemic heart disease, was transferred to an acute geriatric psychiatric facility on a 72-hour involuntary hold. The transfer was initiated by a Certified Nurse Practitioner (CNP) following an incident where the resident was verbally aggressive and allegedly attempted to strike another resident, although no physical contact was made. The facility did not provide a 30-day or emergency discharge notice to the resident or their representative, and there was no adequate documentation of behaviors that would justify the transfer. Interviews with various staff members, including the Administrator, Director of Nursing (DON), and Social Services Director, revealed inconsistencies in the documentation and communication regarding the resident's behavior and the decision to transfer. The CNP who authorized the transfer later acknowledged that the initial report of the resident's behavior was inaccurate, as the resident did not physically assault another resident. Despite this, the facility did not allow the resident to return after the hospital stay, and no formal discharge notice was provided, leaving the resident without a place to return to. The facility's actions were further scrutinized through interviews with hospital staff and the Long Term Care Ombudsman, who indicated that the facility refused to accept the resident back and did not provide the necessary discharge documentation. The hospital staff described the situation as patient dumping, as the resident was left without a long-term care option. The facility's policy on permitting residents to return after hospitalization was not followed, as the discharge was not justified by the resident's health or behavior, and the facility failed to meet the regulatory requirements for a facility-initiated discharge.
Failure to Provide Discharge Notice
Penalty
Summary
The facility failed to provide the appropriate written notice of discharge to a resident and their representative, which is a requirement when a resident is transferred or discharged. The resident, who had medical diagnoses including Alzheimer's disease and congestive heart failure, was transferred to an acute, inpatient geriatric psychiatric facility on an involuntary hold due to a behavioral incident. Despite the transfer, the facility did not issue a 30-day or emergency discharge notice to the resident or their representative, as confirmed by interviews with the hospital staff, family members, and facility administrators. The facility initially held the resident's bed but later decided not to allow the resident to return without notifying the resident or their representative. The hospital social worker attempted to coordinate the resident's return, but the facility refused to accept the resident back and did not provide a formal discharge notice. This lack of communication and failure to follow proper discharge procedures led to the resident remaining at the hospital, despite their desire to return to the facility.
Failure to Allow Resident Return After Therapeutic Leave
Penalty
Summary
The facility failed to allow a resident to return after a therapeutic leave to an acute, inpatient, geriatric psychiatric facility, which exceeded the bed-hold policy. The resident, who had Alzheimer's disease, spinal stenosis, congestive heart failure, and ischemic heart disease, was transferred to the psychiatric facility on a 72-hour involuntary hold due to perceived aggressive behavior. However, the facility did not provide a 30-day or emergency discharge notice to the resident or their representative, which is required when a facility-initiated discharge occurs. Interviews with various staff members and hospital workers revealed discrepancies in the documentation and communication regarding the resident's behavior and the decision not to readmit them. The facility's Administrator and Director of Nursing acknowledged that the resident did not physically assault another resident, contrary to what was documented on the pink slip form. Despite the resident's desire to return to the facility, the facility's social worker indicated an intention to avoid readmitting the resident, and the resident's belongings were removed from the facility without a formal discharge notice. The facility's policy on permitting residents to return after hospitalization or therapeutic leave was not followed, as the facility did not meet the necessary requirements for a facility-initiated discharge. The facility's actions were perceived as patient dumping by hospital staff, and the resident was left without a clear plan for returning to the facility or an alternative placement, leading to confusion and distress for the resident and their family.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 128 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Tiffin
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Willows At Tiffin | 1.5 mi | ★★★★★ | 0 | 0 |
| St Francis Senior Ministries | 1.7 mi | ★★★★★ | 0 | 0 |
| St Catherine's C C Of Fostoria | 11.6 mi | ★★★★★ | 16 | 0 |
| Spring Creek Nursing And Rehabilitation Center Llc | 11.6 mi | ★★★★★ | 10 | 0 |
| Good Shepherd Home | 11.7 mi | ★★★★★ | 1 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Autumnwood Care Center.
100% money-back within 48 hours.
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.