All citations for Autumn Lake Healthcare at Windsor

State inspectors check nursing homes that take Medicare or Medicaid against federal rules, usually about once a year, and also look into complaints. Each rule a home did not meet is a citation.

Back to Autumn Lake Healthcare at Windsor

Last standard health inspection on record

March 11, 2026

Showing 1 to 19 of 19 citations

  1. No harm, with potential for more than minimal harm

    Develop and maintain an Emergency Preparedness Program (EP).

    Widespread (many residents). CMS level F.

    Emergency preparedness citation E-0004, Emergency Preparedness Deficiencies. Inspection of March 12, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (February 27, 2024).

  2. No harm, with potential for more than minimal harm

    Establish emergency prep training and testing.

    Widespread (many residents). CMS level F.

    Emergency preparedness citation E-0036, Emergency Preparedness Deficiencies. Inspection of March 12, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (February 27, 2024).

  3. No harm, with potential for more than minimal harm

    Establish staff and initial training requirements.

    Widespread (many residents). CMS level F.

    Emergency preparedness citation E-0037, Emergency Preparedness Deficiencies. Inspection of March 12, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (February 27, 2024).

  4. No harm, with potential for more than minimal harm

    Keep aisles, corridors, and exits free of obstruction in case of emergency.

    Widespread (many residents). CMS level F.

    Fire safety citation K-0211, Egress Deficiencies. Inspection of March 12, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (February 27, 2024).

  5. No harm, with potential for more than minimal harm

    Have approved installation, maintenance and testing program for fire alarm systems.

    Widespread (many residents). CMS level F.

    Fire safety citation K-0345, Smoke Deficiencies. Inspection of March 12, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (February 27, 2024).

  6. No harm, with potential for more than minimal harm

    Install corridor and hallway doors that block smoke.

    Widespread (many residents). CMS level F.

    Fire safety citation K-0363, Smoke Deficiencies. Inspection of March 12, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (February 28, 2024).

  7. No harm, with potential for more than minimal harm

    Meet requirements for operating features, such as evacuation plans, fire drills, smoking regulations, draperies, decorations and the inspection, testing and maintenance of fire doors.

    Widespread (many residents). CMS level F.

    Fire safety citation K-0700, Miscellaneous Deficiencies. Inspection of March 12, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (February 27, 2024).

  8. No harm, with potential for more than minimal harm

    Provide a written emergency evacuation plan.

    Widespread (many residents). CMS level F.

    Fire safety citation K-0711, Miscellaneous Deficiencies. Inspection of March 12, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (February 27, 2024).

  9. No harm, with potential for more than minimal harm

    Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.

    Pattern (more than a few residents). CMS level E.

    Fire safety citation K-0223, Egress Deficiencies. Inspection of March 12, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (February 27, 2024).

  10. No harm, with potential for more than minimal harm

    Inspect, test, and maintain automatic sprinkler systems.

    Pattern (more than a few residents). CMS level E.

    Fire safety citation K-0353, Smoke Deficiencies. Inspection of March 12, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (March 14, 2024).

  11. No harm, with potential for more than minimal harm

    To conduct inspection, testing and maintenance of fire doors by qualified individuals.

    Pattern (more than a few residents). CMS level E.

    Fire safety citation K-0761, Miscellaneous Deficiencies. Inspection of March 12, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (February 27, 2024).

  12. No harm, with potential for more than minimal harm

    Meet requirements for the installation and maintenance of electrical systems.

    Pattern (more than a few residents). CMS level E.

    Fire safety citation K-0911, Gas, Vacuum, and Electrical Systems Deficiencies. Inspection of March 12, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (February 27, 2024).

  13. No harm, with potential for more than minimal harm

    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.

    Isolated (one or a few residents). CMS level D.

    Fire safety citation K-0222, Egress Deficiencies. Inspection of March 12, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (February 27, 2024).

  14. No harm, with potential for more than minimal harm

    Have stairways and smokeproof enclosures used as exits that meet safety requirements.

    Isolated (one or a few residents). CMS level D.

    Fire safety citation K-0225, Egress Deficiencies. Inspection of March 12, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (March 7, 2024).

  15. No harm, with potential for more than minimal harm

    Install emergency lighting that can last at least 1 1/2 hours.

    Isolated (one or a few residents). CMS level D.

    Fire safety citation K-0291, Egress Deficiencies. Inspection of March 12, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (February 27, 2024).

  16. No harm, with potential for more than minimal harm

    Properly select, install, inspect, or maintain portable fire extinguishes.

    Isolated (one or a few residents). CMS level D.

    Fire safety citation K-0355, Smoke Deficiencies. Inspection of March 12, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (February 27, 2024).

  17. No harm, with potential for more than minimal harm

    Meet other general requirements that are deficient.

    Isolated (one or a few residents). CMS level D.

    Fire safety citation K-0500, Services Deficiencies. Inspection of March 12, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (February 27, 2024).

  18. No harm, with potential for more than minimal harm

    Ensure proper usage of power strips and extension cords.

    Isolated (one or a few residents). CMS level D.

    Fire safety citation K-0920, Gas, Vacuum, and Electrical Systems Deficiencies. Inspection of March 12, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (February 27, 2024).

  19. No harm, with potential for more than minimal harm

    Ensure proper storage of liquid oxygen.

    Isolated (one or a few residents). CMS level D.

    Fire safety citation K-0930, Gas, Vacuum, and Electrical Systems Deficiencies. Inspection of March 12, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (February 27, 2024).

Source: CMS Provider Information, Fire Safety Deficiencies, Health Deficiencies, Citation Code Look-up, data as of October 1, 2026. Inspection results describe the home at the time of each inspection.