Autumn Woods Health Campus

Based on observation, record review, and interview, the facility failed to ensure glucometers (portable device used to measure blood sugar levels) were cleaned per manufacturer guidelines for infection control when obtaining blood sugar readings for 3 of 3 residents observed. (Residents 11, 39, and 34) Findings include:1. During an observation, on 4/29/26 at 8:14 a.m., Licensed Practical Nurse (LPN) 4 obtained Resident 11's blood sugar reading, using the glucometer. After the resident's blood sugar reading was completed, LPN 4 returned to the medication cart with the glucometer. She obtained the bleach wipe, and the glucometer was wrapped in the bleach wipe for two minutes, without cleaning or wiping down the glucometer. The LPN removed the glucometer from the wipe and placed the glucometer on the bottom of the top drawer of the medication cart to dry. There was no barrier placed on the drawer bottom. During an interview, on 4/29/26 at 8:20 a.m., LPN 4 indicated she cleaned the glucometer for two minutes, then let it dry. 2. During an observation, on 4/29/26 at 11:30 a.m., LPN 6…

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 observation, record review, and interview, the facility failed to ensure a resident with Urinary Tract Infection (UTIs) was provided proper management of the urinary catheter drainage system by maintaining the drainage system off the floor for 1 of 3 residents reviewed for bowel and bladder. (Resident 25) Findings include:During an observation, on 4/28/26 at 10:02 a.m., Resident 25's indwelling urinary catheter and tubing were lying flat directly on the floor. The tubing was coiled up around the catheter. The resident was lying asleep in bed. During an observation, on 4/30/26 at 9:20 a.m., the resident was in bed and the resident's indwelling urinary catheter was hanging on the bedrail with the bottom slightly off the floor. Licensed Practical Nurse (LPN) 7 lifted the resident's catheter bag up for the resident to roll onto her right side and placed it onto the resident's bed. The indwelling urinary catheter bag slid from the bed, and the LPN attempted to catch it. The LPN lifted the resident's indwelling urinary catheter bag above the level of the resident's bladder to…

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 interview and record review, the facility failed to ensure residents (Resident D and Resident E) plan of care accurately reflected documented behaviors for 2 of 4 residents reviewed for comprehensive care plans. Findings include: 1.The clinical record for Resident D was reviewed on 11/6/25 at 10:50 a.m. The resident's diagnoses included, but were not limited to, Alzheimer's disease, dementia and psychotic disorder with delusions. The progress note, dated 9/5/25 at 1:11 p.m., indicated the resident had been resistive to care, attempted to hit staff and grab at the staff's wrists while staff attempted to dress him.The progress note, dated 9/18/25 at 4:39 p.m., indicated the resident had been aggressive with staff. The resident punched a staff member in the face and the punched another staff member in the stomach.The progress note, dated 9/24/25 at 9:36 a.m., indicated the psychiatric nurse practitioner had given an order to increase the resident's Rexulti (medication used for agitation) due to increased agitation and physical aggression towards the staff.The progress note,…

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 interview, the facility failed to ensure appropriate interventions were implemented to prevent falls for 5 of 7 residents reviewed for accidents. (Residents 73, 57, 51, 55, and 12) Findings include: 1. During an interview, on 4/1/25 at 10:17 a.m., Resident 73's family member indicated when the resident was in a room on the Legacy Lane Unit, while being transferred from the wheelchair to the bed, a fall occurred. A lift chair was supposed to have been used and the Certified Nurse Aides (CNAs) decided to transfer Resident 73 from the shower to the bed in a wheelchair. There were no peddles on the wheelchair and the resident's feet dropped to the floor. When the resident's feet hit the floor, the resident fell forward from the wheelchair and the resident's face hit the floor. The wheelchair had pedals available since admission, but they were taken off by the staff. During an observation of the resident, on 4/3/25 at 10:54 a.m., the resident was sitting in a wheelchair in…

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 and interview, the facility failed to ensure the physician was notified in a timely manner for 1 of 5 residents reviewed for a significant change in condition. (Resident 35) Findings include: The record for Resident 35 was reviewed on 4/3/25 at 11:23 a.m. The residents's diagnoses included, but were not limited to, pleural effusion, acute respiratory syncytial virus, hypertensive heart disease with heart failure, endocarditis, dementia, cardiomegaly, and edema. The physician's order, dated 12/30/24, indicated the resident was prescribed furosemide 20 milligrams (mg) once a day for bilateral lower extremity edema. The Quarterly Minimal Data Set (MDS) assessment, dated 3/3/25, indicated the resident was moderately cognitively intact. The nurse's note, dated 12/25/24 at 3:07 p.m., indicated Resident 35 presented with pitting edema to the bilateral lower extremities. The left leg was observed to be worse with 2+ edema (4mm of depression rebounding in 15 seconds or less) and the right lower extremity had +1 edema. The resident complained of mild pain to the lower…

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 observation, record review, and interview, the facility failed to ensure a resident with a history of Urinary Tract Infection (UTIs) was provided proper management of the urinary catheter drainage system by maintaining the drainage system off the floor for 1 of 4 residents reviewed for bowel and bladder. (Resident 51) Findings include: During an observation, on 4/3/25 between 11:45 a.m. and 12:22 p.m., Resident 51 was sitting in the Legacy Lane Dining Room in her wheelchair. Resident 51's urinary catheter bag was two thirds full of urine which was sitting on the floor. The tubing was also lying on the floor with yellow urine and sediment in the tubing. The resident's feet were stepping on the tubing as the resident moved the wheelchair forward and backward. The resident began rolling away from the table with the catheter bag and tubing dragging the floor. The catheter bag could be heard scrapping the floor as it was dragging on the floor. There were 8 to 10 staff members in the dining room during the observation. During an observation, on 4/4/25 at 8:15 a.m., Resident 51…

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 and interview, the facility failed to ensure a resident's weight was verified for 1 of 5 residents reviewed for nutrition and hydration. (Resident 35) Findings include: The record for Resident 35 was reviewed on 4/3/25 at 11:23 a.m. The resident's diagnoses included, but were not limited to, pleural effusion, acute respiratory syncytial virus, hypertensive heart disease with heart failure, endocarditis, dementia, cardiomegaly, and edema. The physician's orders, dated 12/30/24, indicated the resident was prescribed furosemide 20 milligrams (mg) once a day for bilateral lower extremity edema. The Quarterly Minimal Data Set (MDS) assessment, dated 3/3/25, indicated the resident was moderately cognitively intact. The care plan, dated 3/31/25, indicated the resident had experienced significant weight loss. The interventions included, but were not limited to, offer the resident encouragement and assistance with eating, weights as ordered by the physician, and provide diet, supplements, medications, adaptive equipment, and snacks as ordered. The nurse's note, dated…

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 and interview, the facility failed to ensure showers were provided consistently for 4 of 4 residents reviewed for ADL (Activities of Daily Living) care. (Residents F, C, D, K) 1. The record for Resident F was reviewed on 2/21/24 at 11:03 a.m. The diagnoses included, but were not limited to, chronic obstructive pulmonary disease, immobility syndrome, morbid obesity, muscle weakness, abnormalities of gait and mobility, difficulty walking, and spinal stenosis. The care plan, dated 5/16/22, indicated the resident required staff assistance to complete ADL tasks completely. The Profile Care Guide care plan, dated 5/20/22, indicated the resident received showers on Tuesdays and Fridays and used a full body mechanical lift for transfers. The Quarterly MDS (Minimum Data Set) assessment, dated 1/26/24, indicated the resident was moderately cognitively impaired, had limited range of motion in both of his lower extremities, and was dependent on a helper for showering and bathing. The shower…

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 observation, interview, and record review, the facility failed to ensure there were enough staff to assist residents with activities of daily living in a timely manner related to bathing, incontinence care, and falls related to sufficient staffing. This deficient practice had the potential to affect 79 of 79 residents residing in the facility. Findings include: During an interview on 2/20/24 at 9:30 a.m., the DON (Director of Nursing) indicated staffing was based on the budget and acuity. They would then adjust as needed. If there were call-ins, they attempted to get coverage, but if they were not able to fill the shift, then leadership management would cover the shift, even if it was the CNA (Certified Nurse Aide) position. They haven't had any more than the usual call outs by staff. She indicated the following staff were scheduled: - Legacy Lane (200 and 300 Halls), were staffed with two nurses and three CNAs for both day and night shifts. They usually staffed twelve-hour shifts, but some staff worked eight-hour shifts. - The 100 Hall was staffed with one nurse and one…

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 observation, record review and interview, the facility failed to ensure the kitchen was maintained in a sanitary manner for 5 of 5 observations. This deficient practice had the potential to affect all 79 of 79 residents currently residing at the facility. Findings include: 1. During the initial tour of the kitchen on 2/19/24 between 9:25 a.m. and 10:00 a.m., while in the presence of the Assistant Director of Food Service, the following concerns were observed: - The knife holder next to the stove had a film of moderate dust across the top where the knives entered. - The reach in freezer in the dry storage - inside the door frame at the bottom corner there were large yellow food particles; the bottom shelf of the 3 door unit had a heavy soil of tan and yellow food crumbs and green beans. - The reach-in freezer in the kitchen - the bottom shelf of both sides had a moderate amount of crumbs on it. - Both of the reach in freezers and reach in refrigerator had moderate smears and streaks down the stainless steel doors. - The tilt skillet - both sides, edges and floor on both…

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 and interview, the facility failed to ensure post-dialysis monitoring of a dialysis access site for 1 of 1 resident's reviewed for dialysis. (Resident D) Findings include: The clinical record for Resident D was reviewed on 2/21/24 at 08:46 a.m. The diagnoses included, but were not limited to, infection and inflammatory reaction due to other cardiac and vascular devices, implants and grafts, hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease, and dependence on renal dialysis. The Quarterly MDS (Minimum Data Set) assessment, dated 12/19/23, indicated the resident was cognitively intact. The care plan, initiated on 9/8/21, indicated the resident had renal failure resulting in a need for dialysis. The interventions included, but were not limited to, assess access site for signs of localized infection such as swelling, redness, pain or tenderness, heat at the area, purulent drainage, bloody/malodorous dialysate and observe catheter site per orders. The Registered Dietician dialysis note, dated 2/13/24 at 3:49 p.m.,…

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 observation, record review, and interview, the facility failed to ensure the monitoring and safety of residents with dementia for 2 of 5 residents reviewed for falls. (Residents B and J). Findings include: 1. The record for Resident B was reviewed on 2/20/24 at 1:40 p.m. The diagnoses included, but were not limited to, a traumatic subdural hemorrhage without loss of consciousness, injury of the face, second degree atrioventricular block, epilepsy, dementia, contusion of part of the head, and repeated falls. The care plan, dated 9/28/22 and revised on 12/29/23, indicated the resident had a traumatic brain injury with a subdural hematoma related to a fall. The interventions included, but were not limited to; dated 9/28/22, allow sufficient time to complete self-care, encourage maximum participation of the resident during self-care activities, monitor for the presence of pain or intolerance during self-care activities, praise the resident for efforts, provide adequate rest periods between self-care activities, provide a private, non-distracting environment for self-care…

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 and interview, the facility failed to ensure a resident did not receive a psychotropic medication in an excessive dosage without adequate documentation for its use for 1 of 5 residents reviewed for unnecessary medications. (Resident 30) Finding includes: The record for Resident 30 was reviewed on 2/20/24 at 1:55 p.m. The diagnoses included, but were not limited to, Alzheimer's disease; dementia in other diseases classified elsewhere without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety; depression; and psychotic disorder with delusions due to known physiological condition. The Quarterly Minimum Data Set (MDS) assessment, dated 9/28/23, indicated the resident had severe cognitive impairment with frequent trouble sleeping and concentrating and wandered frequently but not daily. No hallucinations or delusion were present. A care plan, dated 8/2/22 with a last review date of 12/28/23, indicated the resident was at risk for adverse consequences related to receiving antipsychotic medication for psychotic disorder with delusions due to…

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 observation, record review, and interview, the facility failed to ensure a staff member with COVID-19 and symptoms was isolated and tested prior to working with the residents for 1 of 5 staff observed for infection control. Findings include: During an observation on 2/22/24 at 8:15 a.m. LPN (Licensed Practical Nurse) 4 began to prepare medications for Resident 14. During the observation, the LPN had audible congestion, was sniffling, and appeared generally unwell. He began to have perspiration during the medication administration of medications to Resident 14. During an interview on 2/22/24 at 8:38 a.m., after completing the medication administration as he drew up insulin for Resident 14, he indicated he had started with sinus pressure on 2/21/24. On 2/22/24, he was a little warm and had body aches. He probably needed to test himself for COVID-19, but had not done so yet. He had not let anyone know he wasn't feeling well. He had just come in and went straight to work. He then went into Resident 14's room and administered her insulin to her. During an observation on 02/22/24…

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.