Autumn Lane Health And Rehabilitation

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident and staff interviews, and record review, the facility failed to provide staff assistance with activities of daily living (ADLs), bathing, and oral hygiene, for one (Resident (R) 78) of two residents reviewed for ADLs out of a sample of 18 residents. This failure had the potential to negatively impact the quality of life for the affected resident. Findings include: Review of R78's Face Sheet located in the Admissions tab of the electronic medical record (EMR) revealed R78 was admitted on [DATE] with diagnoses including intracerebral hemorrhage, hemiplegia, muscle weakness, and dysphagia. Review of R78's quarterly Minimum Data Set (MDS) located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 4/21/2025 revealed a staff assessment of cognitive skills for daily decision making that indicated R78 was moderately cognitively impaired. The MDS also indicated R78 was dependent on staff for bathing and oral hygiene. Review of R78's Care Plan, dated 10/24/2024, located…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, record review, and review of the facility policy titled Medication Administration-General, the facility failed to ensure a medication error rate below five percent. During medication administration for two residents (R) (R45 and R77), the correct dosage of medication was not administered to the residents. These failures caused two medication errors out of 25 opportunities for error, or a medication error rate of eight percent. These failures had the potential to increase or decrease the effectiveness of these medications. Findings include: Review of the facility's undated policy titled Medication Administration-General, revealed Medications are administered in accordance with a valid prescriber order. Prior to medication administration, the Nurse or Certified Medication Aide (CMA): Reads the administration directions on the IVAR and verifies correct medication, dose, and directions for use. 1. Review of R45's Face Sheet, located in the Admissions tab of the electronic…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record review, and review of the facility policies titled Wound Care and Hand Hygiene, the facility failed to adhere to infection control practices and policies during wound care related to staff failing to perform hand hygiene during glove changes and placing supplies on resident's dirty bedside table for two of two residents (Resident (R) 81 and R29) observed for wound care in the sample of 22 residents. The deficient practice increased the risk of cross-contamination and infections. Findings include: Review of the facility's undated policy titled Wound Care, provided by the facility indicated, Remove gloves and perform hand hygiene. Put on second clean gloves. Prepare the supplies on a clean surface covered with an impervious barrier. Review of the facility's undated policy titled Hand Hygiene, provided by the facility indicated, Change gloves and perform hand hygiene during patient care, if Gloves become damaged. Gloves become visibly soiled with blood or body fluids…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, and a review of the facility policy titled Skilled Nursing Services, the facility failed to ensure that opened food items were labeled and dated. The facility census was 81, with 79 residents receiving an oral diet. Findings included: A review of the facility policy, Skilled Nursing Services, reviewed 12/30/2022, revealed all items should be covered, sealed, labeled, and dated appropriately. An observation on 9/22/2023 at 8:10 a.m. of the walk-in cooler revealed the following: A baggie containing four eggs was open to air, unlabeled and undated. A baggie containing three eggs was open to the air, unlabeled and undated. A baggie containing two eggs, opened, unlabeled and undated. One five-pound bag of Great Lakes grated cheddar cheese, which was open to the air and unlabeled and undated. One two-pound bag of [NAME] Gusto grated Parmesan cheese, which was open to the air, unlabeled, and undated. An observation of the walk-in-freezer on 9/22/2023 at 8:15 am, revealed a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interviews, and a review of facility policy titled MDS compliance, the facility failed to ensure three of 25 sampled residents (R) (36, 48, and 62). Minimum Data Set assessments were accurate. Findings include: Review of facility policy titled MDS Compliance last reviewed 12/30/2022 revealed 'Each resident's assessment will be coordinated by and certified as complete by a registered nurse, and all individuals who complete a portion of the assessment will sign and certify to the accuracy of the portion of the assessment he or she completed.' 1. Record review of the Physician orders for R36 revealed an order for Indwelling urinary catheter to bedside drainage dated 11/11/2022. Record review of quarterly MDS dated [DATE] revealed section H-Bladder and Bowel, was not marked for indwelling catheter use. 2. Record review of the Physician orders for R48 revealed an order for dialysis three times per week dated 3/29/2023. Record Review quarterly MDS dated [DATE] revealed section O-Special…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, staff interviews, and a review of facility policy titled, Patient's Plan of Care the facility failed to ensure one of 25 resident (R) (62) care plans were updated following completion of the Minimum Data Set assessment. Findings include: Review of facility policy 'Patient's Plan of Care' last reviewed 12/20/2022 revealed 'The patient's care plan should be reviewed after each MDS assessment and revised based on changing goals, preferences and needs of the patient and in response to current interventions. The comprehensive care plan should also be updated as ongoing clinical assessments identify changes.' Record review of a progress note dated 5/14/2023 revealed the gastrostomy tube was removed. Record review of care plan last reviewed 7/9/2023 revealed an intervention to 'Assess feeding tube placement, patency, and residual every shift and before and after administration of any fluids or medications.' Interview on 9/23/2023 at 9:53 am with MDS coordinator confirmed R62 no longer has a feeding tube. Stated the care plan should have been updated to reflect the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, staff interview, and review of the facility policy titled Weight and Nutrition Management, the facility failed to ensure a significant weight loss was reported for one of four residents (R) (R50) reviewed nutrition. Findings include: A review of the facility policy, Weight and Nutrition Management, reviewed 12/30/2022, revealed the facility should identify significant weight changes, discuss nutritional needs and issues through a collaborative interdisciplinary team (IDT) environment, consider possible interventions and monitor the effectiveness of the interventions, and notify the registered dietician for any guidance, follow-up, and assessment needs, or as needed. Record review of R50's weights revealed a 5.97% weight loss in 30 days, 7.35% in 90 days, and 10.0% in 180 days. R50 had a 6.35% weight loss between 8/1/2023 and 9/7/2023. A review of the Nutritional Assessment completed by the Dietary Manager (DM) on 9/20/2023 revealed R50 had a 5.97% weight loss in 30 days, a 7.35% weight loss in 90 days, and a 10.0% weight loss in 180 days. The assessment…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, record review, staff interviews, and review of facility policy titled, Foley Catheter Care, the facility failed to implement an effective Infection Control Program to prevent the spread of infection by not ensuring Certified Nursing Assistant (CNA) AA washed/sanitized her hands during the provision of catheter care for one of three residents (R) (36) with indwelling urinary catheter. Findings Include: Review of facility policy titled Foley Catheter Care last reviewed 12/30/2022 revealed 'Provide routine hygiene for meatal care To avoid contaminating the urinary tract, always clean by wiping away from-never toward-the urinary meatus. Use washcloth and soap and water or plain disposable wipe to clean the periurethral area.' Observation on 9/23/2023 at 10:15 am with CNA AA in R36's room, she was observed explaining to resident that she was going to provide catheter care prior to getting her dressed and out of bed. CNA AA donned gloves and placed one rag in the sink to wet it. CNA AA then proceeded to wash R36's face and placed the rag back in the sink under…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and review of the facility policy titled, Patient's Plan of Care the facility failed to follow the care plan for one of 31 sampled residents (R) (#45). Findings include: Review of Policy titled Patient's Plan of Care (review date 12/4/21): Each patient will have a person-centered comprehensive care plan developed and implemented to meet his other preferences and goals, and address the patient's medical, physical, mental and psychosocial needs. Record review revealed R#45 was admitted to the facility on [DATE] and had the following diagnoses: Cerebral infarction, unspecified, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, Type 2 diabetes mellitus without complications, hypertension, and peripheral vascular disease. Review of Resident's Consolidated Order revealed a No added Salt (NAS) order since 5/18/2020. There was also an order for Mighty Shake one carton by mouth with meals with a start date of 5/12/22. Review of the care plan for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interviews, and review of the facility policy titled, Foley Catheter Care, the facility failed to ensure catheter care was provided in a manner to prevent urinary tract infections for one of five residents (R) (R#61) with indwelling urinary catheters. Findings include: Review of the facility policy titled, Foley Catheter Care with a review date of 12/4/2021 revealed: Intent - to promote hygiene, comfort and decrease risk of infection for patients with an indwelling catheter and is performed daily and PRN (as needed) for soiling. Please see Lippincott Nursing Procedure [NAME] for additional information on how to complete the procedure. [NAME] (2019) documented to avoid contaminating the urinary tract, always clean by wiping away from and never toward the urinary meatus. The policy does not include information about cross contamination and/or using a clean washcloth/wipe for each stroke. Review of the admission Minimum Data Set (MDS) with an assessment reference date of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and staff interview, the facility failed to serve one of 31 sampled resident (R) (#45) a Mighty Shake and a no added salt diet as ordered by the Physician. Findings include: Review of document titled Food Nutrition Services (not dated) revealed: Diet: No Added Salt This diet does not receive any salt packets and avoids added salt at the table. Record review revealed R#45 was admitted to the facility on [DATE] and had the following diagnoses: Cerebral infarction, unspecified, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, type 2 diabetes mellitus without complications, hypertension, and peripheral vascular disease. Review of Resident's Consolidated Order revealed a No added Salt (NAS) order since 5/18/2020. There was also an order for Mighty Shake one carton by mouth with meals with a start date of 5/12/22. There was also a supplement order for House Supplement 150 milliliter by mouth 3 times per day with a start date of 5/12/22. Review…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and staff interviews and review of directions for use of the germicidal bleach wipes the facility failed to maintain sanitary and clean conditions on three of four halls(100, 200, and 300). Specifically, the facility failed to follow kill times when cleaning sinks, toilets, and railings in hallways. Findings include: Review of directions for use of the germicidal bleach wipes revealed to clean and disinfect and deodorize hard, nonporous surfaces - wipe wet surface to be disinfected. Use enough wipes for treated surface to remain visibly wet for the contact time listed on label. To kill Mycobacterium bovis, let stand for 3 minutes. Let air dry. If streaking is observed, wipe with a clean, damp cloth or paper towel after appropriate contact time has expired. 1.Observation of environmental cleaning on the 300 hall in room [ROOM NUMBER] on [DATE] began at 9:06 a.m. and concluded at 9:37 a.m. with Laundry Aide/Housekeeper KK revealed the following: 1.At 9:10 a.m. Central began cleaning the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.