Autumn House of York.

“Medication containers for residents were found unlocked, unattended, and accessible in a trash bin attached to a medication cart. The containers identified residents' names, medication regimens, and diagnoses, violating record confidentiality requirements.”

“Mold spores were found lining a ceiling vent in the 3000-hall near resident room 3118, creating unsanitary conditions.”

“Evidence of a mouse infestation was found in the home, including multiple staff observations of mice in the SDCU common shower room and resident rooms, and mouse droppings located in a resident room.”

“Several areas of carpet in the 3000-hall were bunched up with ridges lifting approximately 1-2 inches from the floor, creating a potential tripping hazard.”

“An approximate two-inch accumulation of lint was found in the lint traps of both the first floor and third floor kitchenette dryers, creating a fire hazard.”

“A resident was pulled out of a chair by another resident on an unspecified date. The home did not report this incident to the Department within the required 24-hour timeframe; the reportable incident form was not faxed to the Department until 7/21/25, several days after the incident on 7/18/25.”

“Multiple resident-to-resident abuse incidents occurred: (1) A resident slapped another resident in the face at 9:15 PM, causing a red mark; (2) A resident pushed another resident, causing a fall and head injury with hematoma; (3) A resident pushed another resident in the bedroom, causing a fall with head and back injuries; (4) A resident pulled another resident's arms to remove them from a chair at 9:00 PM.”

“Multiple sanitary condition violations were observed: (1) A dead mouse on the exterior landing; (2) Mold spores lining a ceiling vent in the 3000 hall; (3) Blood marks on a resident's mattress; (4) A human molar on the floor of a resident room; (5) A recliner with feces-soiled disposable pad and urine-soiled cushion underneath.”

“Evidence of bedbug infestation was observed: a bedbug exoskeleton in a bedframe, 2 dead bedbugs by a closet and baseboard, 2 dead bedbugs under a bed, and 2 dead bedbugs next to a toilet in separate resident rooms. Additionally, evidence of mouse infestation was observed with a mouse running down the 3000 hall and entering a resident bedroom.”

“Civil money penalty assessed. Daily fine of $3 per day for a class III violation based on census of 91 residents, totaling $273 per day.”

“License revoked from certificate of compliance #338220 dated June 26, 2025 until June 26, 2026. A first provisional license issued based on acceptable plan to correct violations.”

“A list of resident information including care needs for mobility, room numbers, and shower schedules was found unlocked, unattended, and accessible in a cabinet in the 3000 hallway.”

“Multiple resident-to-resident incidents of abuse occurred: resident #4 was pushed down by resident #5 and hit their head; resident #4 was slapped in the face multiple times and shoved into a bed by resident #6 resulting in back pain; and resident #7 hit resident #8 with a decorative rock causing a reddened area on resident #8's back. This is a repeated violation.”

“Residents were physically abused by other residents on multiple occasions. One resident pushed/pulled another resident's walker causing a fall; another resident pushed a resident onto the floor resulting in a cut requiring hospitalization; a third incident involved a resident found on the floor with bleeding injuries. Staff failed to prevent these incidents of abuse and mistreatment.”

“From 11:00PM to 7:00AM, only 1 staff person certified in First Aid and CPR was present in the home when residents were present, violating the requirement of at least one certified staff for every 50 residents at all times.”

“Discontinued medications were observed in the home's medication cart. Medications discontinued on 1/13/25 and 1/8/25 were still present in the 2000 hallway medication cart, violating the requirement to keep only current medications in the home.”

“Medications were improperly stored. Opened medications were not dated and loose pills were observed in the medication cart, violating proper storage and sanitation requirements.”

“OTC medications in the medication cart were not labeled with a resident's name, violating the requirement that OTC medications and CAM belonging to residents be identified with the resident's name.”

“Blood glucose readings documented on a resident's MAR did not match the readings recorded in the resident's glucose meter, indicating inaccurate medication administration record documentation. Additionally, a resident's prescribed as-needed medication was not available in the home.”

“Multiple resident-to-resident altercations occurred including physical fights with resulting injuries such as scratches, bruising, and skin tears. Additionally, one incident involved a staff member allegedly injuring a resident, resulting in a 4-inch skin tear; the staff member was terminated.”

“During the 11:00 PM to 7:00 AM shift on 11/1/24, 92 residents were present in the home with only 1 staff person certified in First Aid and CPR, when at least 2 are required for this number of residents.”

“Combustible and flammable materials were located near heat sources or hot water heaters.”

“Common bathrooms in the B200 and B300 hallways had thick layers of dust and debris on exhaust fans, which prevented adequate airflow and ventilation.”

“Walk-in freezer temperature was 20°F on 11/6/24 at 10:45 AM and 15°F on 11/7/24 at 9:51 AM, exceeding the maximum allowable temperature of 0°F for frozen food storage.”

“The home's policy addressed investigating reportable incidents but staff did not conduct formal investigations including gathering and maintaining witness statements. Staff reported incidents directly to medication technicians or supervisors without documenting first-hand accounts, relying only on reportable incident forms.”

“Resident 1's support plan required 15-minute checks for irritability and aggression. On 3 of 10 randomly selected shifts, there was no documentation of these checks occurring. On 7/23/24, staff were unable to locate Resident 1 for several minutes; the resident was found in another resident's bedroom. Staff stated inability to monitor due to bathing another resident.”

“Multiple incidents of physical abuse among residents documented, including punching, choking, pinching, pushing to floors, tackling, and headlock application. One incident involved a contracted agency caregiver who aggressively grabbed a resident's chin and threatened boxing. One resident was hospitalized with a closed head injury. Additionally, staff member's walkie fell and struck a resident's head during care.”

“Bedroom LC10 did not have shades, blinds, or shutters on the windows to provide privacy.”

“Smoking area guidelines not properly maintained. Ten cigarette butts were observed in mulch bed outside home entrance, and staff was observed smoking in an unauthorized area (sidewalk near rear corner) rather than designated smoking areas.”

“A small yellow tablet was found unlocked, unattended, and accessible on the floor outside the medication area in the 1000 hallway, in violation of medication security requirements.”

“Current license inspection summary and chapter copies were not posted in a conspicuous and public place in the home. The most recent inspection summary on file was dated 9/12/23 rather than current.”

“Resident 1, requiring 24-hour direct supervision per assessment and support plan, eloped from the secured dementia care unit and was found several blocks away by police after being outside for approximately 60 to 90 minutes.”

“Multiple incidents of resident-to-resident physical abuse and violence documented in the secured dementia care unit, including: Resident 8 striking Resident 1 in the face; Resident 9 pushing walker into Resident 1; Resident 11 biting off part of Resident 10's ear and kicking; Resident 9 smacking Resident 1; Resident 12 hitting Resident 9; Resident 13 hitting Resident 2 with cane and pushing Resident 9; and Resident 14 striking Resident 15 in the mouth knocking out a tooth. This is a repeated violation from 9/12/23 and 7/18/23.”

“The facility failed to report two resident falls resulting in hospitalizations within 24 hours to the Department. Resident #1 fell and suffered head/face injuries requiring hospitalization but was not reported until 9/8/2023. Resident #2 fell, was hospitalized with closed rib fractures, and was not reported until 7/28/2023.”

“Multiple incidents of resident-to-resident abuse and neglect occurred. Resident #3 engaged in sexual touching, knocked another resident down, grabbed residents' wrists and neck, and pushed another resident causing a skin tear. Resident #4 was hospitalized twice for medication poisoning (Acetaminophen and Aspirin overdoses) after medications were found unsecured in the resident's room despite being locked in the medication cart per policy.”

“Residents were not informed upon admission that interior and exterior entrances were subject to video recording and monitoring, violating the right to privacy.”

“Three resident rooms had enabler devices (bed rails or similar equipment) with safety hazards. Room #2113 had a 4.25-inch gap between mattress and enabler creating entrapment risk. Room #1119 had an uncovered enabler with a 5-inch by 10-inch opening. Room #0311 had an uncovered enabler with a 10-inch by 14.5-inch opening and was not secured to the bed, creating entrapment and fall hazards.”