Autumn Lake Healthcare Post-Acute Care Center

Based on observations, record reviews and staff interviews, it was determined that the facility failed to ensure that respiratory care, including tracheostomy care and tracheal suctioning, was provided consistent with professional standards of practice. This was evident for 4 (Residents #6, #101, #26 and #66) out of 12 residents observed with Tracheostomy tubes during the survey.Findings include:A manual resuscitator, also known as an Ambu bag, is a portable, handheld device used by trained medical professionals to provide positive pressure ventilation to patients who have insufficient or ineffective breathing. The device is essential for emergency situations, such as cardiac arrest, severe asthma attacks, or drug overdoses, to provide oxygen to a patient's lungs until more advanced medical equipment (like a mechanical ventilator) is available. 1. On 11/20/2025 at 7:38 AM, during observation rounds, the surveyor did not observe a manual resuscitator or bag valve mask in Resident #6's room. On 11/20/2025 at 7:42 AM, the surveyor conducted observation rounds Respiratory Therapist…

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 staff interviews, interviews with the family, and record review, it was determined that the facility failed to ensure that each resident's drug regimen was free from unnecessary drugs, such as those in excessive dosage or given for an excessive duration. This was evident for 1 (Resident #208) out of 1 resident reviewed for unnecessary drugs.The findings include:On November 19, 2025, at 2:45 PM, the surveyor spoke with Resident #208's wife regarding the complaint intake. Resident #208's wife explained how she was upset with the facility for double-dosing her husband for 14 days. The wife explained how Resident #208 was very drowsy and looked sedated when she came to visit them. The wife was notified by the methadone program at the hospital of their denial to refill the methadone too soon after 12/30/24. The wife continued to explain how she had asked the nurses several times why Resident #208 was looking like that (sedated), but received no response. On 11/24/25 at 1 PM, the surveyor spoke with the Director of Nursing (DON) #2 and the Regional DON #17 about what happened…

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 staff interviews, interviews with the family, and record review, it was determined that the facility failed to ensure that residents were free of any significant medication errors. This was evident for 1 (Resident #208) out of 1 resident reviewed for medication errors.The findings include:On November 19, 2025, at 2:45 PM, the surveyor spoke with Resident #208's wife regarding the complaint intake. Resident #208's wife explained how she was upset with the facility for double-dosing her husband for 14 days. The wife explained how Resident #208 was very drowsy and looked sedated when she came to visit them. The wife was notified by the methadone program at [NAME] of their denial to refill their methadone too soon after 12/30/24. The wife continued to explain how she had asked the nurses several times why Resident #208 was looking like that (sedated), but received no response.On 11/24/25 at 1 PM, the surveyor spoke with the Director of Nursing (DON) #2 and the Regional DON #17 about what happened with…

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 and interview, the facility failed to ensure the kitchen was maintained in a sanitary manner to prevent the potential for food contamination. This deficient practice had the potential to affect any resident who consumes food prepared in the kitchen.Findings Include:During an observation on 11/18/25 at 9:00 AM, the following were noted in the kitchen food-service area:1. A large pile of dark black substance was observed on the floor under a shelf inside the walk-in freezer.2. The lid holder tray contained dried food residue.3. Chipping paint was observed on a post within the kitchen.4. Standing water was present on the floor near the dishwasher.5. Ten (10) ice cubes were observed spaced out across the kitchen floor.During follow-up observations on 11/19/25 at 10:00 AM and 11/20/25 at 11:00 AM, the above unsanitary conditions remained unaddressed.During an interview on 11/19/25 at 11:00 AM, the Certified Dietary Manager (CDM) (Staff #3) stated that the area should be cleaned each day. She acknowledged that the conditions observed should not have been present.After…

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 staff interviews, interviews with the family, and record review, it was determined that the facility failed to ensure that medical records and forms were complete and accurately documented. This was evident for 3 (Resident #208, Residents #213, and Resident #214) out of 3 resident reviewed for medical records.The findings include:1. On November 19, 2025, at 2:45 PM, the surveyor spoke with Resident #208's wife regarding the complaint intake. Resident #208's wife explained how she was upset with the facility for double-dosing her husband for 14 days. The wife explained how Resident #208 was very drowsy and looked sedated when she came to visit them. The wife was notified by the methadone program at [NAME] of their denial to refill their methadone too soon after 12/30/24. The wife continued to explain how she had asked the nurses several times why Resident #208 was looking like that (sedated), but received no response. On 11/24/25 at 1 PM, the surveyor spoke with the Director of Nursing (DON) #2 and 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 observations and interviews with facility staff it was determined the facility failed to adhere to infection control practices and guidelines to prevent the spread of germs and cross contamination of microorganisms in the facility. This was found to be evident for 5 occurrences 1.) Resident #31 during the initial tour and screening of residents; 2.) Resident #73 during a lunch dining observation; 3.) An observation made during a tour of the laundry area; 4.) An observation of a Clean Linen bin placed within a resident-use bathroom; and 5.) The urinary catheter bag of resident #26 observed on the floor.Findings include: 1. An initial tour of the building was conducted on 11/18/25 at 8:00AM by the survey team and while screening residents and making observations of the resident rooms, the following concerns were identified: Resident # 31's room was observed at approximately 9:00AM and was noted to have an odor present. There was a very large brown dried area noted on the floor underneath the resident bed and to the side. The resident was present in the room and was asked if…

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 medical record review and interview, the facility staff failed to thoroughly investigate a complaint of a neglect (Resident #35). This was evident for 1 out of 39 residents reviewed during a complaint survey. Findings include: Review of Resident #35's facility reported incident (MD 00190514) on 10/8/23 at 11:00 am revealed the resident's family made an allegation of neglect after the resident fell on the unit on 3/14/23 and sustained a fracture leg. The surveyor reviewed the facility investigation on 10/8/24 at 11:30am revealed that the facility failed to thoroughly investigate the events surrounding the allegation of neglect. The investigation contained information about the fall incident on 3/14/24. The facility investigation did not contain other resident interviews disproving widespread negligence from staff. Interview with the Director of Nursing on 10/8/24 at 2:00pm confirmed the facility investigation of Resident #35's did not contain resident interviews disproving widespread negligence from staff.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, and interview with staff it was determined that the facility failed to ensure residents received treatment and care in accordance with professional standards of practice as evidenced by 1.) failure to follow physician orders for 1 of 8 (Resident #155) residents reviewed for pressure ulcers, and 2 of 10 (Resident #40 and #19) residents reviewed for physician orders; 2.) failure of the GNA to notify the nurse after a resident had a fall for 1 of 5 (Resident # 609) residents reviewed for falls; 3.) failure of the facility to ensure that a resident received treatment for a possible wound infection for Resident #359, and 4.) failure to administer a pain medication for Resident #87 as ordered by the physician. This was found to be evident during the facility's annual Medicare/medicaid survey. The findings include: 1. Failure to follow physician orders regarding pressure ulcer dressing change On 3/14/23 at 2:30 PM surveyor observed Registered Nurse (RN) #76 doing a dressing…

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 staff interview it was determined that the facility staff failed to store, prepare, and serve food and beverages using proper sanitary practices. This deficient practice has the potential to affect all residents in the facility. Findings include: An initial tour of the facility's kitchen was conducted on 02/21/23 at 08:15 am with the Dietary Manager (DM) #27 present. After surveyors sanitized hands and donned hairnets. Dietary Aid (DA) #34 entered the kitchen, passed surveyors and DM #27, opened, and entered a storage refrigerator without sanitizing their hands. The DM #27 was alerted to the observation and asked what was the expectation of staff entering into the kitchen. The DM #27 replied that it was expected that all personnel sanitize their hands before entering any area of the kitchen, including the refrigerator. Observation of the storage refrigerator found and undated, opened partially exposed package of shelved cheese. Observation of the food preparation area revealed several storage racks with opened spices, seasonings food dyes,…

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, medical record review and interviews, it was determined that the facility staff failed to provide an environment that promotes the dignity and respect for residents. This was found to be evident for Residents #16, #158, #37 and #362 and residents in Rooms #14, #18, #19, #20 sampled during the facility's annual Medicare/Medicaid survey. The findings include: 1. Review of the facility reported incident MD00178528 dated 6/9/2022 and MD00178603 dated 6/10/2022, revealed that on 5/15/22 the facility received an accusation of resident to employee abuse by GNA #38, a contracted staff member. The Director of Nursing (DON) started the facility investigation of the abuse incident on 5/15/22. The facility had video surveillance of the area where the abuse incident was alleged to have taken place. The facility investigation was completed by 5/18/22 which substantiated GNA #38 violated facility policy by committing gross misconduct as shown in the video footage of the 5/15/22 abuse incident. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, resident and staff interviews, it was determined that the facility staff failed to provide and maintain a safe, clean, and homelike environment for the residents. This was evident for 2 (3rd floor Dementia Unit and the Terrace Unit) of 4 units observed during the survey. Findings Includes: 1. A tour of the 3rd floor Dementia unit was conducted on 02/21/23 at 08:00 AM where a loose partially attached bumper panel on the left side of elevator door casing was observed. Multiple dark stains, black streaks, dents, and holes were noted on the lower portion of the unit's hallway. Further observation revealed folded candy wrappers located inside the handrail ledge near the unit's utility closet. An observation of the unit's dining room at 08:40 am revealed 5 dining chairs with their seat areas pushed in and frayed fabric dangling from their bottoms. Observation of the two window seals and air conditioning units revealed a plastic cup with a dried substance inside sitting on the left…

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 an administrative record review and interviews with the facility staff it was determined the facility failed to complete a thorough investigation into allegations of abuse. This was found to be evident for 4 (Residents #609, #42, # 356, and # 361) of 20 residents reviewed for abuse during the facility's annual Medicare/Medicaid survey. The findings include: 1. Intake MD00184687 was reviewed on 3/15/23 at 10:00 AM for allegations of abuse. According to the intake information, Resident #609's family reported to the facility on [DATE] that the resident was pushed from the wheelchair by Geriatric Nurse Assistant (GNA) #89. The facility DON was asked on 3/15/2023 at 10:15 AM if they had an investigation into the allegations and the facility subsequently provided the survey team with documentation of Resident #609 sustaining a hematoma to the forehead from a fall that occurred on 10/12/22 in the afternoon. Further review of the documentation on the same date at 10:30 AM included interviews with other…

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 staff interview it was determined that the facility failed to: 1.) ensure that a plan of care was adjusted to reflect significant weight loss for (Resident #60) reviewed for nutrition and 2.) revise care plans with appropriate goals and interventions for 2 (Resident #155 and Resident #178) of 8 residents reviewed for pressure ulcers, 2 (Resident #155 and Resident #188) of 5 residents reviewed for tube feeding, and 1 (Resident #188) of 3 residents reviewed for tracheostomy and 1 (Resident #178) 1 residents reviewed for anticoagulant therapy during the facility's annual Medicare/Medicaid survey process. Findings include: The Minimum Data Set (MDS) is a federally mandated assessment tool used by nursing home staff to gather information on each resident's strengths and needs. The MDS provides a comprehensive assessment of the resident's functional capabilities and helps nursing home staff identify health problems. It is designed to collect the minimum amount of data to guide care planning and monitoring for residents in long-term care settings. A care plan is…

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, observation, and interview, it was determined that the facility staff failed to: 1.) administer a medication in accordance with the standards of practice for residents (Resident #87, #186, #117, #158, #84, #556) and 2.) document after medications were administered for residents (#172, #121, #155, #122, #188, #514 and #41). This was evident for 13 of 20 residents selected for review during a medication chart check during the facility's annual Medicare/Medicaid survey. The findings include: 1. Review of Resident #87's medical record on 3/5/23 at 9 pm revealed an ordered for Melatonin 3 MG (Milligrams) by mouth at bedtime for insomnia. The melatonin was to be administered at 9 pm with administration signed as given. Review of the Medication Administration Record (MAR) for 3/1/23 at 9 pm revealed the Nurse, LPN #5 documented the Melatonin as being administered at 11:10 pm. During interview with the DON (Director of Nurse) on 3/5/23 at 10 pm, she verified the findings. During interview with the LPN #5 she stated the standard of practice is to administer 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 QAPI record review and interview, the facility failed to adequately monitor its practices around abuse, specifically abuse prevention, abuse reporting, and abuse investigation. The facility had repeat deficiencies for abuse prevention, abuse reporting and abuse investigation during this annual survey after submitting a plan of correction in January 2022. Findings include: On 3/21/23 at 7:30 am, review of facility's previous survey findings revealed the facility had deficiencies for abuse prevention, abuse reporting, and abuse investigations in January 2022. The facility submitted a Plan of Correction in January 2022 to address the deficiencies and the the Plan of Corrections was approved. On 3/21/23 at 7:40 am, review of deficient practices found during the facility's annual survey revealed repeated deficient practice for abuse prevention, abuse reporting, and abuse investigations. On 3/21/23 at 11:30am, during an interview with the Assistant Director of Nursing (ADON) and the QAPI Custodian #4, the surveyor revealed the survey team found repeated deficiencies around abuse…

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 accommodate the needs of a resident by failing to ensure a resident had the medical equipment needed for their disability status. This was evident in 1 of 72 (Resident #103) residents reviewed during the facility's annual survey. The findings include: On 2/22/23 at 11:32 am, the surveyor observed Resident #103 with bilateral lower extremity edema sitting in a wheelchair without the foot rests. The surveyor interviewed Resident #103 regarding the resident's needs. Resident #103 stated he/she requested wheelchair footrest, but the facility had failed to meet the request. Review of the medical records on 3/9/23 at 3:33 PM revealed a podiatry note dated 2/23/23 which revealed Resident #103 was diagnosed with insufficient blood flow to his/her lower extremities. The loss of blood flow to the lower extremities put Resident #103 at risk for pressures ulcers at his/her lower extremities so pressure relieving devices were needed per podiatry recommendations. On 03/09/23 04:30 PM, the surveyor interviewed the Assistant…

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 interviews with the resident and facility staff it was determined the facility failed to ensure that a newly admitted resident received breakfast the following morning after being admitted . This was found to be evident for 1 (Resident # 607) of 107 residents sampled during the facility's annual Medicare/Medicaid survey. The findings include, Residents that resided on the first floor were screened on 2/21/23 at 11:00 AM in accordance with the Long-Term Survey Process. During a brief interview each resident was asked if they are doing okay and if they have any concerns regarding the care that they were receiving at the facility. Upon entering Resident # 607's room, the resident was asked if there were any concerns regarding the care that was provided by the staff, and the resident replied, I did not get breakfast today. The resident further stated that no one came in to bring breakfast to him/her. An interview was conducted immediately with Licensed Practical Nurse (LPN) #8 at 11:05 AM and he was made aware that Resident #607 did not receive a breakfast…

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 medical record review and interviews it was determined that the facility failed to notify the physician when a resident refused medications that have the potential to adversely affect their health when missed. This deficient practice was evident in 1(Resident #107) of 5 medical records reviewed for physician notification. The findings include: On 03/02/23 at 12:29 pm, a review of Resident #107's Medication Administration Record (MAR) for February 2023 revealed the resident missed a dose of the antispasmodic medication on 02/01/23 at 8:00 am. Antispasmodics are used to relieve cramps or spasms of the stomach, intestines, and bladder. Further review of the MAR revealed that the resident refused 11 doses of a Statin medication for high cholesterol and 10 doses of an Anticholinergic for an Overactive Bladder. On 03/02/23 at 1:14 pm during an interview with Director of Nursing (DON) #2 when asked what the expectations of the staff are when a resident misses a medication or treatment, the DON reported the staff are to notify the provider, call the pharmacy to see why 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 resident and staff interviews it was determined that the facility staff failed to report an allegation of verbal abuse to the state agency within two hours. This was evidenced in 1 (Resident #42) of 5 records reviewed for abuse. The finding includes: On 03/06/23 at 2:45 pm during an interview, Resident #42 stated he/she reported to Social Services Designee #24 that a female GNA came into the room on the evening of 03/04/23 badgering the resident about leaving the facility. The alleged GNA told the resident they didn't want him/her there. On 03/06/23 at 3:14 PM during an interview, Social Services Designee #24 indicated Resident #42 mentioned something happened over the weekend and Social Services Designee #24 reported it to Unit Manager #13. On 03/06/23 at 3:28 PM, in interview with Administrator #1 and the Director of Nursing #2, both verbalized being unaware of the alleged incident of verbal abuse that took place on the Terrace Level during the evening shift of 03/04/23 which verified the staff did not report the alleged abuse to the state agency within two hours. On…

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 medical record review and interviews with facility staff it was determined the facility failed to ensure that the resident and or the resident responsible party (RP) received a written transfer notice with documentation of the reason for the transfer to the hospital prior to transfer. This was found to be evident for 3 (Residents #161, #166, and #556) of 4 residents reviewed for hospital transfers during the facility's annual Medicare/Medicaid survey. The findings include: 1. A medical record review was done on 2/23/23 at 2:56 PM and it revealed R# 161 was sent to the hospital. The resident had a change of condition on 4/19/22 and was sent to the hospital for further evaluation. The survey team requested a copy of the facility's transfer form that was provided to the resident upon transfer. The facility was unable to provide this document. The resident was sent to the hospital on [DATE]. The survey team requested a copy of the facility's transfer form that was provided to the resident upon transfer. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview with staff it was determined that the facility failed to have a system in place to ensure that residents or resident responsible party (RP) are given written notification of the facility bed-hold policy when they are being transferred out of the facility to a hospital. This was found to be evident for 3 (Residents #161, #166, and #556 ) of 4 residents reviewed for hospital transfers during the facility's annual Medicare/Medicaid survey. The findings include, 1. A medical record review was done on 2/23/23 at 2:56 PM and it revealed Resident #161 was sent to the hospital due to a change of condition on 4/19/22. The survey team requested a copy of the facility's bed-hold form that was provided to the resident upon transfer. The facility was unable to provide this document to the survey team. The resident was sent to the hospital on [DATE]. The survey team requested a copy of the facility's bed-hold form that was provided to the resident upon transfer. The facility 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview with the facility staff it was determined that the facility failed to ensure Minimum Data Set (MDS) assessments accurately reflected the resident's status as evidenced by: 1.) failure to accurately code: speech, vision, hearing, health condition and pain for 1 (Resident #155) of 2 residents reviewed for pain; 2.) failure to accurately code a resident for falls for 1 (Resident #506) of 5 residents reviewed for falls and 3.) failure to accurately code a resident for bowel and bladder incontinence for 1 (Resident #163) out of 5 residents reviewed for bowel and bladder incontinence during the investigation stage of the survey. The findings include. The MDS is a federally mandated assessment tool used by nursing home staff to gather information on each resident's strengths and needs. The MDS provides a comprehensive assessment of the resident's functional capabilities and helps nursing home staff identify health problems. It is designed to collect the minimum amount 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.

Based on medical record review and interview with staff it was determined that the facility staff failed to develop a care plan to 1.) reflect the presence of and current treatment of the residents' behavior for 1 of 5 (Resident #188) residents reviewed for unnecessary medications; 2.) to reflect a resident who required staff to provide care and mobility for 1 out of 4 (Resident #155) reviewed for mobility and 3.) reflect the specific care for a resident who was admitted with a Foley catheter (Resident #410). This deficient practice was evident for 3 of 10 residents reviewed for care plans during the facility's annual Medicare/Medicaid survey. The findings include: A care plan is a guide that addresses the unique needs of each resident. It is valuable in preventing avoidable declines in functioning or functional levels. It must reflect immediate steps for assuring outcomes which improve the resident's status and progress. 1. Review of Resident #188's medical records on 03/15/23 04:23 PM revealed the resident was admitted to the facility for long term care and with diagnosis that…

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 and interviews it was determined that the facility failed to follow the proper procedures to safely transfer a resident. This was evident for 1 of 8 residents (Resident #93) reviewed for accidents during the facility's annual Medicare/Medicaid survey. The findings include: A Hoyer lift is a patient lift used by caregivers to safely transfer patients. It can be used for lifting patients from the floor or onto a healthcare bed. The lift also can assist in other surface-to-surface patient transfers, such as moving from a bed to a bath or chair. such as moving from a bed to a bath or chair. On 3/16/23 at 11 AM the surveyor observed a resident in the middle of the hallway being hoisted up from his/her chair and the 2 staff members transported the resident from the hallway into the room During an interview with geriatric nursing assistant (GNA) #78 the surveyor asked what resident was being transported into the room, she replied it was Resident #93. The surveyor asked what the procedure for moving a resident from the Hoyer lift into a bed. GNA #78 informed 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interviews it was determined that the facility failed to maintain infection control practices. This deficient practice was evident in 2 (Resident #48 and #133) of 2 residents observed with urinary drainage bags and 1 treatment cart located on the Terrace Level. The findings are: On 02/21/23 at 8:19 am during observation rounds on the Terrace Level, the surveyor observed the treatment cart located outside of room [ROOM NUMBER] was unlocked. Drawer #2 had used wound cleanser without a resident label, opened and exposed gloves, and gauze. Drawer #3 had a package of opened and exposed abdominal pads. Drawer #4 had an open package of Calcium Alginate, an open package of 4 x 4 gauze, and unpackaged gauze in Drawer #5. On 02/21/23 at 8:27 am LPN #14 confirmed the surveyor's findings on the treatment cart. On 02/21/23 at 8:44 am while in Resident #133's room, surveyor observed the leg of the bedside table was over the resident's urinary drainage bag on the floor. The resident's phone, 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 observation and interviews it was determined the facility failed to ensure all residents had access to a working call bell system. This deficient practice was evident in 1 of 7 (Resident #30) residents reviewed for a working call bell system. The findings include: On 3/09/23 at 6:08 pm, while on the Terrace Level in room [ROOM NUMBER], Resident #30 came into the room via wheelchair and verbalized being cold. The surveyor instructed the resident to initiate the call bell for assistance. The surveyor observed the resident press the call bell twice. After five minutes none of the staff came to room [ROOM NUMBER]. The surveyor went outside of the room and noticed the call bell light outside of the resident's room was not on. The surveyor went to the nurse's station to get assistance for Resident#30. LPN #80 came to the resident's room and verified the call bell system for resident #30 was not working. The nurse connected the call bell cord to a y-connector and the call bell light came on. On 03/10/23 at…

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 facility staff interviews with the DON (Director of Nursing) and record review, the facility failed to provide a written notice to a resident and the responsible party of the transfer for 3 out of 3 people reviewed for transfer out to the hospital. Findings include: 1. On 3/28/19 at 11:33 AM a record review of resident # 9 was conducted. Resident # 9 was sent to the hospital on 1/13/19 for abdominal fullness and leaking around the supra pubic site. The nursing note stated the supra pubic catheter will need to be changed by interventional radiology at the hospital. An interview with the DON (Director of Nursing) was held on 3/28/19 at 11:33 AM, who showed the survey team a booklet which contained the information sent out with the resident. During this conversation DON stated the packet is given to the EMT (emergency medical team) driver. All paperwork including face sheet, Molst form, Transfer note, labs, Physician note, nurse note, consults and bed hold policy was given to EMT driver. NO care plan was sent out with resident. DON confirmed the Bed hold policy was not given…

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 facility staff interviews with the DON (Director of Nursing) and record review, the facility failed to provide a written notice to a resident and the responsible party of the transfer for 3 out of 3 people reviewed for transfer out to the hospital. Findings include: 1. On 3/28/19 at 11:33 AM a record review of resident # 9 was conducted. Resident # 9 was sent to the hospital on 1/13/19 for abdominal fullness and leaking around the supra pubic site. The nursing note stated the supra pubic catheter will need to be changed by interventional radiology at the hospital. An interview with the DON (Director of Nursing) was held on 3/28/19 at 11:33 AM, who showed the survey team a booklet which contained the information sent out with the resident. During this conversation DON stated the packet is given to the EMT (emergency medical team) driver. All paperwork including face sheet, Molst form, Transfer note, labs, Physician note, nurse note, consults and bed hold policy was given to EMT driver. DON confirmed the Bed hold policy was not given to the resident. DON could not locate or…

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 resident observation, responsible party and staff interviews it was determined that the facility staff failed to follow enteral feeding standards of practice. This was evident for 1 out of 2 residents selected for Tube Feeding review involving resident #105 during the investigative portion of the survey process. When a person cannot eat any or enough food because of an illness. Others may have a decreased appetite, difficulties in swallowing, or some type of surgery that interferes with eating. When this occurs, and one is unable to eat, nutrition must be supplied in a different way. One method is enteral nutrition or tube feeding. Risk of aspiration should be assessed individually and appropriate interventions (e.g., proper positioning, rate of flow) implemented accordingly. The finding includes: On 4/3/19 at 10:15 A.M. during resident #105 observation who was admitted to facility with multiple medical diagnosis which includes but not limited to requiring enteral nutrition for daily nutritional needs to be met. 04/03/19 10:15 A.M. during resident #105 observation surveyor…

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 and staff interview it was determined that facility staff failed to treat residents with respect and dignified manner by knocking on resident's room doors before entering. This was evident for 2 out of 53 residents involving (R#105, and #192) observed during dining meal service. The finding include: 04/02/19 12:20 P.M. during second floor nursing unit lunch meal service observed geriatric nursing assistant (GNA) staff member #3 go in rooms [ROOM NUMBERS] without knocking on resident's doors and not sanitizing hands between rooms with lunch meals trays. On 04/02/19 12:20 P.M. conducted staff interview with staff member #3 who informed writer the meaning of resident's dignity, and infection control practices. Staff member #3 verbally verified he/she forgot to knock on the resident's room door before entering and didn't wash or sanitized his/her hands between rooms during lunch meal service. 04/02/19 12:25 P.M. conducted staff interview with Nurse Unit Manager staff member #4 with who 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview with resident, observation of resident and a review of medical records, the facility failed to identify a resident with Dental issues. This was evident for 1 out of 53 residents with dental issues. Findings include: On 3/28/19 at 1:56 PM resident # 358 was interviewed. It was observed that resident had missing teeth and and discolored gums in the upper and lower gums. Resident stated they are decayed. Resident also stated no one here has looked at his/her mouth , nor has she/he had a dental appointment due to fact she/he had no dental insurance. Resident also stated she/he needed to see a dentist. On 3/1/19 when resident was admitted to the facility the admission assessment done by nurse at the time of admission did not identify the condition of resident's dental status. A conversation was on 4/4/19 at 11:38 AM with staff # 1, who is the MDS coordinator. The MDS dated [DATE] section L oral/dental status states there was no issue. (no broken teeth, no tooth fragments, no broken natural teeth.…

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 interview with resident, observation of resident and a review of medical records, the facility failed to identify a resident with Dental issues. This was evident for 1 out of 53 residents with dental issues. Findings include: On 3/28/19 at 1:56 PM resident # 358 was interviewed. It was observed that resident had missing teeth and and discolored gums in the upper and lower gums. Resident stated they are decayed. Resident also stated no one here has looked at his/her mouth , nor has she/he had a dental appointment due to fact she/he had no dental insurance. Resident also stated she/he needed to see a dentist. A conversation was had with staff # 1 on 4/4/19 at 11:38 AM who is the MDS coordinator. Nursing home MDS (minimal data set) coordinators maintain patient records adhering to state and federal regulations. They work closely with medical and administrative staff to continuously update patient records, and in most cases, handle the RAI (resident assessment instrument) process for patients from admission…

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 interview with resident, observation of resident and a review of medical records, the facility failed to identify a resident with Dental issues and a resident who is on dialysis. This was evident for 2 out of 53 residents without a base line care plan. Findings include: 1. On 3/28/19 at 1:56 PM resident # 358 was interviewed. It was observed that resident had missing teeth and and discolored gums in the upper and lower gums. Resident stated they are decayed. Resident also stated no one here has looked at the mouth , nor has she had a dental appointment due to fact she has no dental insurance. Resident also stated she need to see a dentist. A conversation was had with staff # 1 who is the MDS coordinator on 4/4/19 at 11:38 AM. The MDS admission assessment reveals that section L oral/dental status states there was no issue. (no broken teeth, no tooth fragments no broken natural teeth. Staff #1 said she would review MDS and get back to me. Upon her return MDS coordinator confirmed the MDS was coded…

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 interview with resident, observation of resident and a review of medical records, the facility failed to identify a resident with Dental issues and a resident who is on dialysis. This was evident for 2 out of 53 residents without a comprehensive care plan. Findings include: 1. On 3/28/19 at 1:56 PM resident 358 was interviewed. It was observed that resident had missing teeth and and discolored gums in the upper and lower gums. Resident stated they are decayed. Resident also stated no one here has looked at the mouth , nor has she had a dental appointment due to fact she has no dental insurance. Resident also stated she need to see a dentist. A conversation was had with staff # 1 who is the MDS coordinator on 4/4/19 at 11:38 AM. Nursing home MDS (minimal data set) coordinators maintain patient records adhering to state and federal regulations. They work closely with medical and administrative staff to continuously update patient records, and in most cases, handle the RAI (resident assessment instrument)…

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 and staff interviews it was determined that the facility staff failed to develop a care plan for Resident #119 with a diagnosis of dementia. This was evident for 1 out of 53 Residents investigated during the survey process. The Findings Include: On 04/05/19 around 09:21 AM, this surveyor was reviewing Resident #119's medical record. It was noted that the Resident has a diagnosis of dementia. Further review of the record revealed that there were no interventions in the care plan for a resident with cognitive difficulties. A Care Plan is a formal process that includes correctly identifying existing needs, as well as recognizing potential needs or risks. This allows nursing to identify interventions to assist the Resident with any barriers that interferes with the Resident's optimal level of health.