Autumn Lake Healthcare at Greenfield
Below-average Medicare ratings — review the inspection history and ask the administrator about recent corrections before visiting.
based on 96 Google reviews

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Quality Concerns Identified
Medicare inspection and quality data reveal areas that families should carefully evaluate before choosing this facility.
- Abuse citation on record
- Low overall rating (1/5 stars)
- Above-median deficiencies (28 vs median 7)
- High staff turnover (73%)
- High RN turnover (72%)
Bottom 25% in WI · Meets national RN staffing standard · Above recommended total nurse staffing · Very high staff turnover · Worst in AUTUMN LAKE HEALTHCARE chain · $176,440 in fines · Abuse citation
What this means for your family
While the facility is physically modern and has a capable rehab team, the recurring reports of severe neglect, bed bugs, and medication errors are critical red flags. If you choose this facility, you must be prepared to be a highly active advocate, visit at varying times, and closely monitor your loved one's medical care and hygiene.
Google Reviews
Google Reviews
96 reviews on Google“Autumn Lake Healthcare at Greenfield receives highly polarized feedback, with many families reporting severe neglect, unsanitary conditions, and poor management, while others praise the facility for its physical appearance and specific staff members. Critical issues frequently cited include bed bug infestations, medication errors, and slow response times to call lights, particularly during night shifts. Families considering this facility should be aware of significant inconsistencies in care quality and reports of unprofessional administrative communication.”
Quality Themes
Tap a score for detailsStrengths
- Modern, clean, and well-maintained building
- Effective physical and occupational therapy programs
- Some highly dedicated and compassionate individual staff members
- Spacious and comfortable private rooms
Concerns
- Bed bug infestations in resident rooms (mentioned by 3 reviewers)
- Medication errors and mismanagement (mentioned by 3 reviewers)
- Neglect regarding hygiene, bathing, and basic care (mentioned by 5 reviewers)
- Unresponsive or rude administrative leadership (mentioned by 6 reviewers)
- Slow or non-existent response to call lights (mentioned by 4 reviewers)
- Understaffing and reliance on agency workers (mentioned by 3 reviewers)
Rating Trends
Tap a year to see what changed
Distribution · 101 analyzed
How They Respond to Reviews
This facility actively engages with reviewer feedback.
Questions for Your Tour
- 1Given the recent focus on facility maintenance, what specific protocols are currently in place to ensure ongoing room hygiene and pest prevention?
- 2I noticed that medication management is a high priority for our family; could you walk us through the safeguards and double-check systems you have in place to prevent errors?
- 3How does your nursing team prioritize and respond to call lights, and what is the expected turnaround time for a resident needing assistance?
- 4I appreciate that the leadership team is active in responding to feedback online; how do you incorporate that family input into your day-to-day operations and staff training?
- 5With the therapy programs being a noted strength here, how do you integrate those sessions into a resident's daily routine to ensure they stay active and engaged?
- 6Could you describe the process for how staff monitors and assists residents with daily hygiene and bathing to ensure consistent, high-quality care?
Personalized based on this facility's data
Key Review Excerpts
“My sister was in this facility for less than a week and I had to call 911 to have her taken to the ER. She had a blood infection from a neglected PICC line and unsanitary practices by staff.”
“The night staff was absolutely terrible. I had to help my mom call the main line in several occasions because the call light was on and no one would come. One night worker told her “my back hurts, I ain’t coming back in here no more.””
“Their physical and occupational therapists, with their expertise and kind inspiring words, gave my mom the motivation she needed to recover. The nurses and CNAs were so compassionate.”
Staffing
Staffing Hours
per resident/day · Medicare 2026This facility meets the national staffing benchmarks. Higher staffing is linked to fewer falls and better day-to-day care.
Quality Measures
Quality Measures
Resident outcomes compared with national, state, and local averages · 17 measures
14
measures
3
measures
Residents needing more daily help over time
Residents with depression symptoms
Highly dependent on how each facility screens and codes depressive symptoms, so it varies widely between facilities.
Residents vaccinated for pneumonia
Residents whose bladder or bowel control got worse
Residents whose walking got worse
Residents on antipsychotic medication
Short-stay residents vaccinated for pneumonia
Short-stay residents vaccinated for the flu
Short-stay residents newly given antipsychotics
US average from Medicare published data
Inspection History
Medicare Inspection History
3-year lookback · Medicare 2026
Families have filed complaints that triggered nearly half of the 95 deficiencies found across 12 surveys, with recurring issues in pressure ulcer prevention, resident safety, and medication management. The facility has struggled with serious problems including an abuse case requiring immediate protection, medication errors exceeding acceptable rates, and repeated failures in wound care and accident prevention that persist across multiple years of inspections, though all violations show correction dates.
Dec 13, 2025Complaint5
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Quality of Life and Care Deficiencies
Provide safe and appropriate respiratory care for a resident when needed.
Nutrition and Dietary Deficiencies
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Resident Assessment and Care Planning Deficiencies
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Jul 8, 2025Complaint1
Resident Rights Deficiencies
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Mar 26, 2025Complaint10
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Respond appropriately to all alleged violations.
Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies
Provide enough food/fluids to maintain a resident's health.
Pharmacy Service Deficiencies
Ensure that residents are free from significant medication errors.
Administration Deficiencies
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Nursing and Physician Services Deficiencies
Post nurse staffing information every day.
Dec 12, 2024Routine16
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Emergency Preparedness Deficiencies
Provide emergency officials' contact information.
Gas, Vacuum, and Electrical Systems Deficiencies
Have generator or other power source capable of supplying service within 10 seconds.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Construction Deficiencies
Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction.
Resident Rights Deficiencies
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Resident Assessment and Care Planning Deficiencies
Assure that each resident’s assessment is updated at least once every 3 months.
Resident Assessment and Care Planning Deficiencies
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Resident Assessment and Care Planning Deficiencies
PASARR screening for Mental disorders or Intellectual Disabilities
Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Quality of Life and Care Deficiencies
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Pharmacy Service Deficiencies
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Smoke Deficiencies
Have approved installation, maintenance and testing program for fire alarm systems.
Miscellaneous Deficiencies
Have simulated fire drills held at unexpected times.
Dec 12, 2024Complaint1
Quality of Life and Care Deficiencies
Provide safe, appropriate pain management for a resident who requires such services.
Sep 25, 2024Complaint3
Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Federal Penalties
Fine
Dec 13, 2025
$26,925
Fine
Aug 13, 2024
$125,694
Payment Denial
Aug 13, 2024
54-day denial
Ownership & Operations
Who Operates This Facility
Autumn Lake Healthcare at Greenfield
for profit
Chain Affiliation
Autumn Lake Healthcare
60 facilities nationwide
Chain avg rating: 2.8/5 · Rank 56 of 60 (Worst)
Ownership & Management
Owners
AL Three LLC
Owner · Organization
Davis, Yehoshua
Owner
Wisconsin Acquisitions LLC
Owner · Organization
Markstein, Isaac
Owner
Klein, Joseph
Individual is an Owner, Partner or Trustee of Any Adp of the Snf
Lichtenstein, Simcha
Individual is an Owner, Partner or Trustee of Any Adp of the Snf
Lowy, Joel
Individual is an Owner, Partner or Trustee of Any Adp of the Snf
Markstein, Aaron
Individual is an Owner, Partner or Trustee of Any Adp of the Snf
Markstein, Avrohom
Individual is an Owner, Partner or Trustee of Any Adp of the Snf
Markstein, Mayer
Individual is an Owner, Partner or Trustee of Any Adp of the Snf
Pines, Esther
Individual is an Owner, Partner or Trustee of Any Adp of the Snf
Silber, Naftali
Individual is an Owner, Partner or Trustee of Any Adp of the Snf
Key personnel
Contact
Get in Touch
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References & Resources
Medicare Care Compare
Official Medicare quality ratings, inspections & staffing data
Google Maps
Photos, directions & neighborhood info
Google Reviews
96 reviews from families & visitors
Official Website
Visit autumnlakegreenfield.com
Medicare data downloads
Original nursing home datasets
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