Below 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 July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Autumn Care Of Suffolk during CMS and state inspections, most recent first.
The facility failed to ensure that residents and/or their representatives had the opportunity to develop an Advance Directive for 19 out of 24 residents reviewed. Surveyors found that the facility did not provide the required written information about formulating advance care plans. Only 13 residents had a tracking form on record, and none documented the provision of written information. The facility's procedure did not meet regulatory requirements for advance care planning.
The facility staff failed to review and revise care plans and involve residents or their representatives in the planning process. A resident reported not being invited to care plan meetings, and another resident's care plan was not reassessed for effectiveness. Additionally, responsible parties were not informed or included in the care plan process, and specific requests regarding medication were not addressed.
The facility staff failed to administer medications as ordered for several residents, including gabapentin and anti-hypotensive drugs, citing unavailability and documentation errors. A resident's blood sugar levels were not monitored according to orders, with no physician notification for low levels. The facility's policies on medication shortages and physician communication were not followed.
A facility failed to assess a resident for the appropriateness of self-administering medications, despite a physician's order allowing the resident to keep an albuterol inhaler at the bedside. The resident, who was cognitively intact and had multiple diagnoses, did not have a documented assessment as required by facility policy. The deficiency was identified during a surveyor's review, and the issue was discussed with the facility's administration.
The facility failed to conduct required Level I PASARR screenings for two residents before admission, despite their diagnoses indicating potential mental disorders or intellectual disabilities. One resident had schizophrenia and schizoaffective disorder, while the other had suicidal ideations and vascular dementia. Both residents were moderately impaired cognitively. The facility lacked a specific PASARR policy and could not provide completed screenings when requested by surveyors.
A facility failed to develop a comprehensive, person-centered activity care plan for a resident with severe cognitive impairments and multiple diagnoses, including hemiplegia and epilepsy. The resident, who was on hospice care, lacked a care plan that included measurable objectives and timetables to address mental and psychosocial needs. The deficiency was identified through staff interviews and document reviews, revealing non-compliance with facility policies on care planning.
A facility failed to provide a person-centered activity program for a resident on hospice care with severe cognitive impairment. The resident's records lacked an activity care plan, initial assessment, and progress notes. The activity director admitted to not having a schedule for one-to-one visits and could not provide necessary documentation, despite the facility's policy requiring a resident-centered program.
A facility failed to maintain accurate accounting of morphine sulfate for a resident with Alzheimer's and pain, resulting in 12.75 ml unaccounted for. Despite policies requiring daily narcotics counts and immediate reporting of discrepancies, the facility did not adhere to these protocols. The issue was discussed with the administration, but the discrepancies were not appropriately addressed.
The facility staff failed to act on pharmacist recommendations for three residents, leading to deficiencies in medication management. One resident did not receive a timely AIMS assessment despite being on Quetiapine, another experienced a delay in discontinuing omeprazole despite a priority recommendation, and a third resident did not receive timely AIMS assessments while on Risperidone. These issues were discussed with the facility's administration, but no further information was provided before the exit conference.
Three residents experienced significant medication errors. One resident's blood pressure medication was held without a physician's order, another did not receive prescribed medications due to unavailability, and a third continued to receive morphine after a discontinue order. These issues were discussed with the facility's administration, but no further information was provided.
The facility failed to obtain necessary lab tests for two residents as ordered by medical providers. One resident with type II diabetes did not receive a scheduled HgbA1c test, and another resident with multiple health issues did not have a CBC with differential conducted. These deficiencies were noted during a survey, and the facility administration was informed.
The report highlights deficiencies in a facility's communication and documentation regarding medication management for two residents. One resident's anti-hypotensive medication was held without notifying the physician, while another resident's responsible party was not informed of medication changes, including discontinuations and a new morphine order. The facility's policy on notifying relevant parties was not followed, leading to these deficiencies.
A resident continued to receive morphine despite a hospice order to discontinue it, due to poor communication between facility and hospice staff. The order was not implemented, and the resident received morphine on multiple occasions. The facility's policy requires timely communication, but the order's delay was not addressed, and the family had previously requested the discontinuation.
Failure to Ensure Advance Directive Opportunities for Residents
Penalty
Summary
The facility staff failed to ensure that residents and/or their representatives had the opportunity to develop an Advance Directive for 19 out of 24 residents reviewed. The facility's policy requires that Advance Care Planning be conducted upon each patient's admission, with a meeting to discuss preferences such as Living Wills and Medical Power of Attorney. However, surveyors found that the facility did not provide written information about formulating advance care plans as required by regulations. During the survey, it was noted that the facility had changed its clinical record software, which may have contributed to the difficulty in locating documentation concerning advance care planning in resident records. Upon reviewing the records of 24 residents, surveyors found that only 13 had a tracking form on record, while 11 did not have any documentation of a care planning discussion. None of the tracking forms documented the provision of written information to the residents or their representatives. Additionally, the only options documented as chosen by residents were Full Code and Do Not Resuscitate, with no documentation of other care-limiting orders or Durable Power of Attorney. The surveyors concluded that the facility did not have a procedure that met regulatory requirements for providing written information about advance care planning and ensuring a meaningful opportunity for residents to formulate and implement these plans.
Failure to Review and Revise Care Plans and Involve Residents
Penalty
Summary
The facility staff failed to ensure that comprehensive care plans were reviewed and revised by the interdisciplinary team and did not involve residents or their representatives in the planning process for several residents. For Resident #28, the staff did not review the care plan after the comprehensive assessment and failed to invite the resident or their representative to participate in care planning. Despite being cognitively intact, Resident #28 reported only attending one care plan meeting and did not recall receiving any invitations. The facility's policy required invitations to be sent at least five days prior to the meeting, but no evidence of such invitations was found. Similarly, for Resident #61, the facility staff did not review the care plan after the comprehensive assessment and failed to invite the resident or their representative to participate in care planning. The resident, who was moderately impaired in cognition, could not recall being invited to any care plan meetings. The facility's policy mandates that invitations be sent, but no evidence of invitations or meetings was found for the assessment date. For Resident #83, the facility staff did not reassess the effectiveness of interventions or review and revise the activity care plan to meet the resident's needs. The activity director could not locate an initial activity assessment or progress notes and admitted to not completing quarterly progress notes as required by policy. Additionally, for Resident #40 and Resident #206, the facility staff failed to inform or include the residents' responsible parties in the care plan process and did not provide evidence of care plan conferences being held. Resident #206's care plan also failed to address a specific request from the responsible party regarding medication administration.
Medication Administration Failures in LTC Facility
Penalty
Summary
The facility staff failed to administer medications according to physician orders for several residents, leading to deficiencies in care. For Resident #33, the staff did not administer gabapentin as ordered, citing the medication as unavailable despite it being listed in the facility's emergency medication supply. The Director of Nursing (DON) acknowledged that the resident sometimes refused medications, but the documentation indicated the medication was not available, not refused. The facility's policy on medication shortages was not followed, as the medication should have been obtained from the emergency supply. Resident #207 also did not receive gabapentin as ordered, with multiple doses missed due to documentation errors and lack of proper retrieval from the Omnicell system. The facility's records and the pharmacy's records did not align, indicating a failure in the medication administration process. The staff involved were either no longer employed or unable to provide clarity on the situation, and the facility administration did not provide further information when questioned. For Resident #100, an anti-hypotensive medication was held without proper documentation or physician notification, despite the absence of hold parameters in the order. The DON confirmed that the physician expected to be contacted if the medication was not administered. Additionally, Resident #20's blood sugar levels were not properly monitored according to medical provider orders, as the staff failed to notify the physician when levels were below the specified threshold. This lack of communication and documentation was acknowledged by the facility's regional director of clinical services.
Failure to Assess Resident for Self-Administration of Medications
Penalty
Summary
The facility staff failed to ensure that a resident was clinically assessed for the appropriateness of self-administering medications. The resident, who was diagnosed with conditions including stiff-man syndrome, pulmonary embolism, and chronic obstructive pulmonary disease, was cognitively intact with a mental status score of 14 out of 15. Despite having a physician's order allowing the resident to keep an albuterol inhaler at the bedside, the facility did not complete a self-administration of medications assessment as required by their policy. The deficiency was identified when a surveyor reviewed the resident's clinical records and found no documentation of the required assessment. The Director of Nursing (DON) provided a self-administration form dated after the surveyor's inquiry, indicating a lack of timely assessment. The facility's policy mandates that the interdisciplinary care team assess each resident's ability to safely self-administer medications, which was not adhered to in this case. The issue was discussed with the facility's administration and clinical services team, but no further information was provided before the surveyor's exit.
Failure to Conduct Required PASARR Screenings
Penalty
Summary
The facility staff failed to conduct a Level I Preadmission Screening and Resident Review (PASARR) for two residents, which is required to determine if a resident has or may have a mental disorder, intellectual disability, or related condition prior to admission. For the first resident, the facility did not obtain the necessary PASARR screening before admission, despite the resident having diagnoses such as schizophrenia and schizoaffective disorder. The resident's cognitive abilities were moderately impaired, as indicated by a Brief Interview for Mental Status (BIMS) score of 10 out of 15. The PASARR was only completed after the surveyor's request, months after the resident's admission. Similarly, the second resident was admitted without a Level I PASARR screening, even though the resident had a history of suicidal ideations and vascular dementia, among other conditions. The resident's BIMS score was 12 out of 15, indicating moderate cognitive impairment. Despite the surveyor's request for evidence of a completed PASARR, the facility was unable to provide one for this resident. The surveyor's investigation revealed that the facility lacked a specific policy for PASARR, and instead, they provided a general document outlining federal requirements for PASARR screenings. This document emphasized that Medicaid-certified nursing facilities must screen applicants with serious mental illness or intellectual disabilities before admission. The facility's failure to adhere to these requirements was discussed in multiple meetings with facility leadership, but no further information was provided to the survey team before the exit conference.
Failure to Develop Comprehensive Activity Care Plan
Penalty
Summary
The facility staff failed to develop and implement a comprehensive, person-centered activity care plan for a resident, identified as Resident #83, who was part of a sample of 24 residents. This deficiency was identified through staff interviews, clinical record reviews, and facility document reviews. Resident #83 had multiple diagnoses, including hemiplegia and hemiparesis following a cerebral infarction, epilepsy, a personal history of transient ischemic attack, unspecified convulsions, and type 2 diabetes mellitus. The resident was also receiving hospice services for end-of-life care. The most recent Minimum Data Set (MDS) assessment indicated that the resident was severely impaired in cognitive decision-making, with short and long-term memory problems, and was rarely or never understood or able to understand others. Upon review of the clinical record and comprehensive care plan, there was no evidence of a person-centered activity care plan for Resident #83. When the surveyor requested evidence of such a plan, the activity director provided a care plan created on the same day, which included vague goals and interventions that were not specific or measurable. The facility's policies on Life Enrichment Assessment and Documentation and Comprehensive Care Planning were reviewed, which stated that care plans should reflect individual needs and include measurable objectives and timetables. However, the facility failed to adhere to these policies for Resident #83, as no comprehensive activity care plan was in place prior to the surveyor's request.
Failure to Provide Person-Centered Activity Program
Penalty
Summary
The facility staff failed to provide an ongoing, person-centered activity program for a resident, identified as Resident #83, who was on hospice services for end-of-life care. The resident had multiple diagnoses, including hemiplegia, epilepsy, and type 2 diabetes mellitus, and was severely impaired in cognitive decision-making with short and long-term memory problems. Despite these needs, there was no evidence of a person-centered activity care plan, initial activity assessment, or activity progress notes in the resident's clinical record and comprehensive care plan. During an interview, the activity director admitted that there was no schedule for one-to-one visits, although the activity staff reportedly took an activity cart around three times per week. The activity director provided hand-written activity participation records and an activity care plan created on the day of the surveyor's request, but could not locate an initial activity assessment or quarterly activity progress notes. The facility's Life Enrichment Programming Policy requires an ongoing resident-centered program based on comprehensive assessments and care plans, which was not adhered to in this case.
Failure to Maintain Accurate Narcotics Accounting
Penalty
Summary
The facility staff failed to maintain an accurate accounting of narcotics for a resident, specifically regarding the medication morphine sulfate. The resident, who had diagnoses including Alzheimer's disease and pain, was prescribed morphine sulfate to be taken as needed for mild pain or shortness of breath. The medication order was discontinued in April 2024, but discrepancies in the narcotics count were identified from July 2023 to April 2024. The Controlled Medication Utilization Record showed several discrepancies in the amount of morphine sulfate, with a total of 12.75 ml unaccounted for by the end of the period. The Director of Nursing (DON) was interviewed and acknowledged that narcotics should be counted every shift, yet the discrepancies were not reported to them. The facility's policy on Inventory Control of Controlled Substances requires that Schedule II controlled substances be counted at each shift change and any discrepancies be reported immediately. However, the facility failed to adhere to this policy, as evidenced by the lack of notification to the DON about the incorrect counts and the absence of the Controlled Substance Count Verification/Shift Count Sheets for the specified period. The issue was discussed with the facility's administration, including the administrator, administrator-in-training, DON, and regional director of clinical services. Despite the facility's policies requiring immediate reporting and investigation of missing medications, the discrepancies in the narcotics count for the resident were not addressed appropriately, leading to a deficiency in pharmaceutical services provided by the facility.
Deficiencies in Medication Management and Pharmacist Recommendations
Penalty
Summary
The facility staff failed to review and act upon pharmacist recommendations for three residents, leading to deficiencies in medication management. For one resident, the staff did not complete an Abnormal Involuntary Movement Scale (AIMS) assessment for two months despite a pharmacy recommendation to do so immediately and every six months thereafter. The resident, who was on Quetiapine for bipolar disorder, had a history of moderate cognitive impairment and was at risk for tardive dyskinesia. The facility's policy required prompt action on such recommendations, but the AIMS assessment was delayed, and the Director of Nursing acknowledged the expectation for timely completion. Another resident was affected by the facility's inaction on a pharmacy recommendation regarding the interaction between clopidogrel and omeprazole, which could reduce the effectiveness of clopidogrel. Despite a clinical priority recommendation for prompt response, the omeprazole was not discontinued until several months later. The facility's policy required immediate action on time-sensitive medication concerns, but the delay in addressing the pharmacist's recommendation was noted during the survey. A third resident did not receive timely AIMS assessments as recommended by the pharmacist. The resident, with severe cognitive impairment and on Risperidone, was at risk for involuntary movements. The pharmacy had recommended monitoring for involuntary movements every six months, but the assessments were not completed within the recommended timeframe. The Director of Nursing could not explain the delay, and the facility's policy did not indicate a different assessment period. These deficiencies were discussed with the facility's administration, but no further information was provided before the exit conference.
Medication Errors Affecting Residents
Penalty
Summary
The facility staff failed to ensure that three residents were free from significant medication errors. For one resident, the staff held the blood pressure medication amlodipine without a physician's order, despite the resident having a diagnosis of hypertension. The medication was not administered on three occasions due to low blood pressure readings, but there were no parameters in the order to justify holding the medication. This issue was discussed with the facility's administration, but no further information was provided before the survey exit. Another resident did not receive their prescribed medications, Xarelto and Lasix, as per the physician's orders. The medications were marked as not administered due to unavailability, even though the facility's emergency medication supply included these medications. This resident had a history of pulmonary embolism and was on anticoagulant and diuretic therapy. The failure to administer these medications was also discussed with the facility's administration, but no additional information was provided before the survey exit. The third resident continued to receive morphine after a verbal order to discontinue the medication was given. The order was not implemented, and the resident received multiple doses of morphine after the discontinue order was issued. The facility's administration was unaware of when the discontinue order was provided to the facility, although it was uploaded into the electronic record. This issue was discussed with the facility's administration, but no further information was provided before the survey exit.
Failure to Obtain Ordered Lab Tests for Residents
Penalty
Summary
The facility staff failed to obtain necessary laboratory tests as ordered by medical providers for two residents. For one resident with a diagnosis of type II diabetes mellitus, a hemoglobin A1C (HgbA1c) test was ordered by the primary care provider on 9/2/24, but the test was not conducted as scheduled. The order was present on the Medication Administration Record (MAR) but was not signed off as completed. A registered nurse confirmed that the test was missed and was subsequently scheduled for a later date. The results, when finally obtained, were within normal limits. For another resident with multiple diagnoses including acute on chronic congestive heart failure, chronic obstructive pulmonary disease, anemia, and type 2 diabetes mellitus, a complete blood count (CBC) with differential was ordered for 5/08/24. However, the clinical record did not contain evidence that the CBC was obtained as ordered. The resident was noted to be severely cognitively impaired, with a brief interview for mental status (BIMS) score of 7 out of 15. The deficiency was communicated to the facility's administration, but no further information was provided to the survey team before the exit conference.
Deficiencies in Medication Management and Communication
Penalty
Summary
The report identifies deficiencies in the facility's communication and documentation practices regarding medication management for two residents. For Resident #100, the facility staff failed to notify the physician when an anti-hypotensive medication, Midodrine, was held due to the resident's blood pressure reading. The clinical record lacked hold parameters for the medication, and there was no documentation of physician notification. The medication was held multiple times without notifying the physician, contrary to the medical director's expectations. For Resident #206, the facility failed to document the notification of the resident's responsible party regarding changes in the resident's medication regimen. Several medications were discontinued, and a new order for morphine was initiated without evidence of communication with the responsible party. The facility's policy required notification of the physician and responsible party for changes in medical treatment, but this was not documented in the resident's clinical record. The deficiencies were discussed with the facility's administration and clinical leadership, highlighting the lack of documentation and communication regarding medication changes. The facility's policy on notifying relevant parties of changes in medical treatment was not adhered to, leading to the identified deficiencies.
Failure to Implement Hospice Order for Discontinuation of Morphine
Penalty
Summary
The facility staff failed to ensure effective communication with hospice staff, resulting in the delayed implementation of a medical order for a resident. Specifically, a verbal order to discontinue oral morphine for a resident was not executed in a timely manner. The order, given by the hospice provider on July 7, 2023, was not implemented, and the resident continued to receive morphine on multiple occasions throughout July. The resident's Medication Administration Record (MAR) indicated that the discontinuation order was not followed, leading to the resident receiving morphine on at least five separate occasions after the order was issued. The facility's policy on hospice care emphasizes the importance of timely and professional communication between facility staff and hospice representatives. However, the Director of Nursing and Assistant Director of Nursing reported that the order to discontinue morphine was not implemented, and the Regional Director of Clinical Services was unable to confirm when the order was communicated to the facility. The hospice Medical Social Worker noted that the resident's family had requested the discontinuation of morphine two weeks prior, but this request was not acted upon. The survey team discussed these communication failures with the facility's administrative and clinical leadership, highlighting the breakdown in coordination between the facility and hospice staff.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 170 citations issued within 25 miles in the last 12 months — including the 2 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.
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Suffolk
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lake Prince Woods, Inc | 1.9 mi | ★★★★★ | 3 | 0 |
| Nans Pointe Rehabilitation And Nursing | 2.1 mi | ★★★★★ | 9 | 0 |
| Windsor Grove Health And Rehabilitation | 9 mi | ★★★★★ | 0 | 0 |
| Northern Cardinal Rehabilitation And Nursing | 11.9 mi | ★★★★★ | 0 | 0 |
| Portside Health & Rehab Center | 13.2 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.