Audubon Health and Rehab

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to ensure a resident was included in the discharge planning process for 1 (Resident #8) of 3 (Resident #8, Resident #118, Resident #120) sampled residents investigated for discharge requirements.Findings:Review of the facility's Discharge Transfer and Planning policy, last revised in 08/2025, revealed, in part, discharge planning shall be initiated by the Social Service Director/Designee with anticipated discharges. Further review revealed the discharge plan shall focus on the residents' discharge goals and the preparation of residents to be active partners for post discharge care. Further review reveled the IDT would include regular re-evaluation of residents to identify changes that required modification of the discharge plan. Further review revealed the interdisciplinary team (IDT) would involve the resident and the resident's representative in the development of the discharge plan and address the resident's goals of care and treatment preferences,…

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, interviews, and record reviews, the facility failed to ensure staff wore proper personal protective equipment (PPE) during personal hygiene care for a resident on Enhanced Barrier Precautions (EBP) (an infection control strategy that used gloves and gowns during high-contact resident care to reduce to spread of infection) for 1 (Resident #39) of 8 (Resident# 2, Resident #5, Resident #9, Resident #11, Resident #27, Resident #39, Resident #67, Resident #69) sampled residents who required EBP. Findings:Review of the facility's EBP policy and procedure, dated 01/2023 and revised on 03/2024, revealed, in part, EBP required the use of a gown and gloves for high contact resident care activities such as providing personal hygiene care. Review of the facility's current list of EBP residents revealed, in part, that Resident #39 was currently on EBP. Review of Resident #39's Care Plan revealed, in part, Resident #39 was on EBP related to Resident #39 having an indwelling devices. Observation on 09/15/2025 at 9:35AM revealed an EBP sign on Resident #39's room door…

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, interviews, and record reviews the facility failed to ensure residents did not have cigarette lighters in their possession and/or rooms for 2 (Resident #32 and Resident #79) of 2 (Resident #32 and Resident #79) sampled residents reviewed for accidents and hazards while smoking. Findings: Review of the facility's Smoking Policies and Regulations dated October 2022 revealed, in part, this policy and procedure was developed to ensure the safety of the residents. Further review revealed cigarette lighters were not permitted in a resident's room and would be kept at the nurses stations. Further review revealed adherence to this policy and procedure would be strictly enforced. Resident #32 Review of the facility's Smoking Task Listing Report dated 09/23/2024 revealed, in part, Resident #32 was identified as an independent smoker. Review of Resident #32's care plan revealed, in part, Resident #32 had a potential for injury related to smoking. Resident #79 Review of the facility's Smoking Task Listing Report dated 09/23/2024 revealed, in part, Resident #79 was…

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 and interview the facility failed to ensure clean items in the facility's laundry room were not kept in the contaminated laundry area. Findings: Observation on 09/23/2024 at 4:00 p.m. of the contaminated area in the laundry room, revealed clean mop heads and clean microfiber cleaning cloths were hanging from rods attached to the wall. Observation on 09/24/2024 at 9:10 a.m. of the contaminated area in the laundry room, revealed clean mop heads and clean microfiber cleaning cloths were hanging from rods attached to the wall. In an interview 09/24/2024 at 11:00 a.m., S4Assistant Director of Nursing/Infection Prevention Control Program indicated clean mop heads and clean microfiber cleaning cloths should not be hung to dry in the contaminated area of laundry room.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, observations, and interviews the facility: 1. Failed to notify a resident's physician of a change in a resident's condition for 3 (Resident #44, Resident #67, and Resident #87) of 25 residents included in the final resident sample; 2. Failed to notify a resident's responsible party of a change in condition for 2 (Resident #44 and Resident #87) of 25 residents included in the final resident sample; and, 3. Failed to notify a resident's hospice agency of a change in condition for 1 (Resident #87) of 25 residents included in the final resident sample. Findings: Review of the facility's Change in Resident Medical Status policy revealed, in part, a facility must immediately inform the resident, consult with the resident's physician, and notify, consistent with his or her authority, the resident representative when there was a need to alter treatment significantly or to commence a new form of treatment. Resident #44 Observation on 09/25/23 at 11:14 a.m. revealed Resident #44's had a border…

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, interviews, and record review the facility failed to ensure: 1. Staff performed hand hygiene per facility policy during catheter care for 1 (Resident #87) of 2 residents (Resident #30 and Resident #87) investigated for catheters; 2. Staff performed hand hygiene per facility policy while serving meal trays to residents in their rooms; and 3. Staff handled soiled linen in a manner to prevent cross contamination of surfaces when 2 Certified Nursing Assistants (CNAs) (S16CNA and S21CNA) placed soiled linen on the floor for 2 (Resident #44 and Resident #87) of 2 residents observed during perineal care (washing the genital and rectal areas of the body) and 1 CNA(S21CNA) placed items used in a resident's room onto the clean linen cart. Findings: Review of the facility's Hand Hygiene policy revealed, in part, hand hygiene is indicated when entering and exiting a resident's room, before and after procedures, and before and after applying gloves. 1. Observation on 09/26/2023 at 3:50 p.m., revealed S21CNA did not perform hand hygiene before putting on gloves to perform…

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, interviews and record review the facility failed to ensure an adaptive call bell was available for a resident with limited range of motion in her hands for 1 (Resident #44) of 30 initial pool residents reviewed for call bell use. Findings: Review of Resident #44's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/04/2023 revealed, in part, Resident #44 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated Resident #44 was cognitively intact, and Resident #44 was totally dependent and required two person physical assistance for bed mobility, transfer, and toilet use. Review of Resident #44's care plan revealed, in part, Resident #44 had functional limited range in her hands related to bilateral hand contractures. Further review revealed, a goal of Resident #44 will be free of injury and complications with interventions that included placing a call light within reach, assisting with ADLs as needed, and providing assistive/supportive devices. Observation on 09/25/23 at 11:14 a.m. revealed Resident #44's had limited range 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 interviews and record reviews, the facility failed to ensure a resident with a new diagnosis of unspecified psychosis was referred to the appropriate state agency for a Preadmission Screening and Resident Review (PASARR) Level II evaluation as required for 1 (Resident #47) of 2 (Resident #47 and Resident #18) sampled residents reviewed for PASARR. Findings: Resident #47 Review of Resident #47's medical record revealed, in part, Resident #47 was admitted to the facility on [DATE]. Review of Resident #47's Level 1 Pre-admission Screening and Resident Review dated 10/16/2021 revealed, in part, Resident #47 was not diagnosed with a mental illness. Review of Resident #47's medical records revealed, in part, Resident #47 received a new mental illness diagnoses of unspecified psychosis and depression on 03/21/2023. Review of Resident #47's Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/23/2023 revealed, in part, Resident #47 had an active diagnoses of psychotic disorder…

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, interviews, and record reviews, the facility failed to ensure a resident's careplan was updated following the residents attempt to exit the facility for 1 (Resident #102) of 3 (Resident #88, Resident #94, and Resident #102) residents investigated for dementia care. Review of Resident #102's medical record revealed, in part, an admission date of 08/22/2022 with a readmission date of 01/03/2023 with a diagnosis of Vascular Dementia with Mood Disturbance. Review of Resident #102's Quarterly Minimal Data Set (MDS) with an Assessment Reference Date (ARD) of 07/19/2023 revealed, in part, Resident #102's Brief Interview for Mental Status Score was 3 which indicated Resident #102 had severe cognitive impairment. Review of Resident #102's Comprehensive Care Plan, with a start date of 08/29/2022, revealed, in part, Resident #102 had a history of wandering and moved around a lot in her wheelchair. Review of Resident #102's nurse's notes revealed, in part, a nurse's note with a date of 09/11/2023 and time of 9:56 a.m. that read is was a late entry for 09/10/2023. 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.

Based on observations, interviews, and record review the facility failed to ensure proper infection control techniques were practiced to prevent urinary tract infection for 2 (Resident #44 and Resident #87) of 2 residents observed for perineal care (washing the genital and rectal areas of the body). Findings: Review of the facility's Perineal Care policy revealed, in part, when providing perineal care to a female resident the genital area should be washed moving from front to back, while using a clean portion of a wash-cloth or pre-moistened wash wipe for each stroke. Resident #44 Observation on 09/26/2023 at 3:17 p.m., revealed, S16Certified Nursing Assistant (CNA) performed incontinence care by wiping Resident #44's rectal area forward into Resident #44's vaginal and urethral area (wiping back to front) three times. Further observation revealed a visible streak of brown was noted on the towel after S16CNA wiped from Resident #44 from back to front. In an interview on 09/27/2023 at 12:11 a.m., S16CNA stated that she should not have wiped Resident #44 from back to front when she…

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.