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based on 59 Google reviews
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Medicare shows an abuse citation on record. Read the linked source details, ask the administrator what corrective action was taken, and independently verify the facility’s current status before deciding.
Autumn Lake Healthcare at Windsor receives highly polarized feedback, with recent reviews showing a sharp divide between praise for individual staff members and severe criticism regarding systemic neglect. Families frequently report concerns about chronic understaffing, slow response times to call bells, and poor communication, while other visitors describe the facility as clean and the staff as compassionate. Prospective families should be aware that while some report successful rehab outcomes, multiple accounts detail significant lapses in basic patient dignity and medical responsiveness.
Quality Themes
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Concerns
Rating Trends
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Distribution · 53 analyzed
Personalized based on this facility's data
Key Review Excerpts
“The social worker (Raul) played a crucial role in discharge planning, and we’ve been thriving at home ever since. He was kind, considerate, and incredibly compassionate.”
“One of the issues was they were short staffed if you call the facility no one answered at the nursing station, the nursing supervisors office, or the rehab center. They weren't always quick to respond when people rang the nurses button because they didn't have enough people.”
“The staff repeatedly failed to get her to the bus that came to pick her up on time (she was unable to move herself), resulting in her missing all of her appointments with doctors. The quality of the food served was extremely poor.”
Both RN and total nursing hours are below the EveryPlace reference benchmarks. Ask the facility how it staffs each shift for current resident needs.
Reference benchmarks (0.75 RN and 4.1 total nursing hours per resident/day) are comparison targets, not current federal minimum requirements.
Resident outcomes compared with national, state, and local averages · 17 measures
12
measures
4
measures
1
measures
Residents with depression symptoms
Highly dependent on how each facility screens and codes depressive symptoms, so it varies widely between facilities.
Residents needing more daily help over time
Residents on antipsychotic medication
Residents vaccinated for pneumonia
Residents vaccinated for the flu
Residents whose walking got worse
Short-stay residents vaccinated for the flu
Short-stay residents vaccinated for pneumonia
Short-stay residents newly given antipsychotics
US average from Medicare published data
Detailed Medicare record · up to 3-year lookback
This facility has significant ongoing issues with families filing abuse complaints and persistent problems in care planning, fire safety, and daily care assistance. Three complaint-triggered deficiencies include a recent abuse protection violation and staffing shortages. Recurring problems span care planning accuracy, wound care, daily living assistance, and extensive fire safety violations including blocked exits and faulty alarm systems. While the facility reports correcting issues, the pattern of repeated deficiencies across multiple surveys suggests systematic challenges with maintaining consistent standards.
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.
Quality of Life and Care Deficiencies
Provide medically-related social services to help each resident achieve the highest possible quality of life.
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.
Administration Deficiencies
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Miscellaneous Deficiencies
Provide a written emergency evacuation plan.
Pharmacy Service Deficiencies
Ensure medication error rates are not 5 percent or greater.
Nursing and Physician Services Deficiencies
Observe each nurse aide's job performance and give regular training.
Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
Nursing and Physician Services Deficiencies
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Pharmacy Service Deficiencies
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Infection Control Deficiencies
Implement a program that monitors antibiotic use.
Infection Control Deficiencies
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Nursing and Physician Services Deficiencies
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Egress Deficiencies
Have exits that are accessible at all times.
Smoke Deficiencies
Install corridor and hallway doors that block smoke.
Resident Rights Deficiencies
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Resident Rights Deficiencies
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
Resident Rights Deficiencies
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
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 Rights Deficiencies
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Resident Assessment and Care Planning Deficiencies
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Resident Assessment and Care Planning Deficiencies
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Resident Assessment and Care Planning Deficiencies
Ensure services provided by the nursing facility meet professional standards of quality.
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies
Provide enough food/fluids to maintain a resident's health.
Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Quality of Life and Care Deficiencies
Provide routine and 24-hour emergency dental care for each resident.
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Infection Control Deficiencies
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Infection Control Deficiencies
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Emergency Preparedness Deficiencies
Develop and maintain an Emergency Preparedness Program (EP).
Construction Deficiencies
Meet other general requirements.
Egress Deficiencies
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Smoke Deficiencies
Provide properly protected cooking facilities.
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Smoke Deficiencies
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Services Deficiencies
Meet other general requirements that are deficient.
Services Deficiencies
Install properly constructed and protected linen or trash chutes.
Miscellaneous Deficiencies
Have simulated fire drills held at unexpected times.
Miscellaneous Deficiencies
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Miscellaneous Deficiencies
Ensure that any exit in an area undergoing construction, repair, or improvements shall be inspected daily to ensure its ability to be used instantly in case of emergency.
Gas, Vacuum, and Electrical Systems Deficiencies
Have generator or other power source capable of supplying service within 10 seconds.
Resident Rights Deficiencies
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Resident Assessment and Care Planning Deficiencies
Ensure each resident receives an accurate assessment.
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.
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.
Emergency Preparedness Deficiencies
Develop and maintain an Emergency Preparedness Program (EP).
Emergency Preparedness Deficiencies
Establish emergency prep training and testing.
Emergency Preparedness Deficiencies
Establish staff and initial training requirements.
Egress Deficiencies
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Smoke Deficiencies
Have approved installation, maintenance and testing program for fire alarm systems.
Smoke Deficiencies
Install corridor and hallway doors that block smoke.
Miscellaneous Deficiencies
Meet requirements for operating features, such as evacuation plans, fire drills, smoking regulations, draperies, decorations and the inspection, testing and maintenance of fire doors.
Miscellaneous Deficiencies
Provide a written emergency evacuation plan.
Resident Rights Deficiencies
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Egress Deficiencies
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Miscellaneous Deficiencies
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Gas, Vacuum, and Electrical Systems Deficiencies
Meet requirements for the installation and maintenance of electrical systems.
Resident Assessment and Care Planning Deficiencies
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Resident Assessment and Care Planning Deficiencies
Plan the resident's discharge to meet the resident's goals and needs.
Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
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.
Quality of Life and Care Deficiencies
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Quality of Life and Care Deficiencies
Provide routine and 24-hour emergency dental care for each resident.
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.
Egress Deficiencies
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Egress Deficiencies
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Egress Deficiencies
Install emergency lighting that can last at least 1 1/2 hours.
Smoke Deficiencies
Properly select, install, inspect, or maintain portable fire extinguishes.
Services Deficiencies
Meet other general requirements that are deficient.
Gas, Vacuum, and Electrical Systems Deficiencies
Ensure proper usage of power strips and extension cords.
Gas, Vacuum, and Electrical Systems Deficiencies
Ensure proper storage of liquid oxygen.
Resident Assessment and Care Planning Deficiencies
Ensure each resident receives an accurate assessment.
Administration Deficiencies
Hire a qualified full-time social worker in a facility with more than 120 beds.
Smoke Deficiencies
Properly provide smoke detection systems in areas open to corridors.
Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Egress Deficiencies
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Miscellaneous Deficiencies
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
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 care and assistance to perform activities of daily living for any resident who is unable.
Quality of Life and Care Deficiencies
Provide safe and appropriate respiratory care for a resident when needed.
Smoke Deficiencies
Install corridor and hallway doors that block smoke.
Services Deficiencies
Meet other general requirements that are deficient.
Gas, Vacuum, and Electrical Systems Deficiencies
Ensure proper usage of power strips and extension cords.
Resident Assessment and Care Planning Deficiencies
Ensure each resident receives an accurate assessment.
Federal Penalties
Fine
Mar 11, 2026
$171,390
Fine
Mar 12, 2024
$19,432
Autumn Lake Healthcare at Windsor
for profit
Owners
Windsor Health and Rehabilitation Center LLC
Owner · Organization
Alatise, Lara
Owner
Key personnel
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Medicare Care Compare
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Google Reviews
59 reviews from families & visitors
Official Website
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Original nursing home datasets
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