Autumn Lake Healthcare At Waugh Chapel

Based on observations and interviews with residents and facility staff, it was determined the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public. This was found to be evident for 2 (#76, #15) of 100 residents reviewed during observational rounds, and 2 (dirty and clean) of 2 laundry areas observed. Findings include:1.During observation rounds conducted on 5/3/26 at approximately 11:00AM, an interview was conducted with Resident #76 and the resident stated that s/he had a difficult time sleeping. The resident went on to say that the air system in his/her room abruptly came on at approximately 1:45 PM on 5/2/26 and was very loud. The resident went on to say that the air system did not turn off until approximately 7:45 AM on 5/3/26, the next day. The resident stated that s/he got very little sleep due to the noise level.A meeting was conducted with the Nursing Home Administrator (NHA #1) on 5/4/26 at approximately 9:35 AM and he was made aware of the resident's concern. The Administrator went on to explain that 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on complaint, reviews of a closed medical record, and staff interview, it was determined that the nursing staff failed to follow a physician's orders for withholding an antihypertensive medication when the resident's blood pressure reading was less than 110 mm/Hg. This was evident for 1 of 2 residents (Resident #1) reviewed during the complaint survey.The findings include:Review of Complaint 2605041 on 11/19/25 at 12 noon revealed an allegation Resident #1 was not receiving quality of care at the facility.Resident #1 was admitted to the facility on [DATE] with diagnoses that include but are not limited to post vascular surgery, arthritis, and hypertension. Resident #1 requires assistance from the nursing staff for some aspects of his/her care.Review of Resident #1's closed medical record on 11/19/25 at 12 noon revealed a physician order, dated 08/09/25, instructing the nursing staff to administer the blood pressure lowering medication, Amlodipine Besylate oral tablet, 2.5 mg, by mouth, one time a day, and…

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 with facility staff, it was determined that the facility failed to maintain the safety of the food items to prevent foodborne illness. This was evident for two nourishment room refrigerators out of two nourishment room refrigerators audited during the recertification/complaint survey. The findings include: During the surveyor's tour of the facility on 03/13/25 at 12:10 PM, the surveyor observed a large zip-lock bag with cooked food items dated 03/08/25 and an uncooked cauliflower, brown to black in color in a plastic bag dated 03/08 in the refrigerator, located in the nourishment room, close to the 400-unit Nurses' station. Licensed Practical Nurse (LPN) staff # 29 validated the findings and removed the resident's food from the refrigerator. The surveyor's further observation on 03/13/25 at 12:20 PM noted apple sauce dated 03/08/25 in the refrigerator, located near the 200-unit Nurses station. Unit secretary staff #37 witnessed and validated the findings and removed the apple sauce from the refrigerator. On 03/13/25 at 12:10 PM, an interview 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 observations, interviews and record reviews it was determined that the facility failed to maintain a resident's dignity by not covering the urinary drainage bag when the resident was being transported to and from rehabilitation activities. This was evident for 1 (Resident #73) of 2 residents reviewed for urinary catheter during a recertification/complaint survey. The findings include: On 3/10/25 at 7:55 AM during the initial tour of the facility, Resident #73 was observed with a Foley catheter, a device that drains urine from the bladder. The catheter was observed attached to a urinary drainage bag 1/3 filled with urine hanging under the bed. The Resident was asleep in bed at the time. 03/10/25 at 11:19 AM the surveyor returned to check on the resident and observed Staff #31, a Certified Occupational Therapy Assistant (COTA) as she wheeled the resident back to their room in a wheelchair. The urinary bag was not covered in a dignity bag, it was hanging on the wheelchair. In an interview with staff #31 she stated that part of her job description was to transport residents 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 a review of facility investigative material and interviews with facility staff, it was determined that the facility failed to ensure that a resident remained free of physical abuse. This was evident for 1 (Resident #92) out of 2 residents reviewed for abuse during the Medicare/Medicaid recertification/complaint survey. The findings include: The Minimum Data Set (MDS) is a standardized and comprehensive assessment screening tool used to identify resident's individual needs and areas of concern. BIMS stands for Brief Interview for Mental Status. It is a screening tool used to assist with identifying a resident's current cognition and to help determine if any interventions need to occur. On 03/11/2025 at 12:09 PM, review of resident's record revealed that on 03/06/2023, Resident #92's BIMS assessments score was 13.0 out of 15.0 which indicated that the resident was cognitively intact around the time of the incident. On 03/11/2025 at 12:29 PM, during review of facility reported incident MD00190653 dated 03/29/2023, Resident #92 told Licensed Practical Nurse (LPN) #32 and…

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 interviews, it was determined the facility staff failed to report an allegation of abuse within 2 hours of the allegation to the regulatory agency, the Office of Health Care Quality (OHCQ). This was evident for 1 (Resident #29) of 3 residents reviewed for abuse during a recertification/complaint survey. The findings include: On 3/11/2025 at 8:38 AM, a review of the investigation report of Facility Reported Incident (FRI) #MD00202441, revealed that on 2/10/2024 Resident #29's daughter notified facility staff that the resident reported that on the previous evening care, the GNA (Geriatric Nursing Assistant) hit her/him on the buttock after s/he by self-admission punched the GNA. A review of the timeline of events revealed that the Director of Nursing (DON) was made aware of the allegation of abuse on 2/10/2024 at 3:00 PM and the Nursing Home Administrator (NHA) on 2/10/2024 at 4:50 PM. However, further review of the investigation report of the FRI revealed documentation that the initial self-report of the allegation of abuse was submitted to the State Survey…

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 interviews with facility staff, it was determined that the facility failed to initiate and develop a comprehensive person-centered care plan for Residents who had frequent urinary tract infections (UTI). This was evident for one Resident (Resident #35), out of one Resident reviewed for urinary tract infections during the recertification/complaint survey. The findings include: On 03/11/25 at 10:15 AM medical record review revealed that Resident #35 had UTIs and used antibiotic therapy on 01/19/24: Keflex, on 05/22/24: Cipro, on 06/05/24: Cipro and on 12/30/24: Bactrim. The care plan was not initiated for risks and prevention of UTI. On 03/11/25 at 9:57 AM, an Interview with Social Services staff # 4 revealed that the Care plans are conducted regularly. The social worker documents the overview of the care plan meeting notes, and individual departments initiate and revise their care plans. On 03/12/25 at 03:59 PM, Reviewed with Infection Preventionist Staff # 1 and validated that Resident #35 ' s care plan did not include the risks and prevention for getting…

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 and medical record reviews, it was determined that the facility failed to review and revise the Resident's comprehensive care plan by an interdisciplinary team (IDT). This was evident for 2 Residents (Residents #13 and #35) out of forty-four Residents reviewed for care plan revisions during the recertification/ Complaint survey. A care plan is used to assess, plan, and evaluate the effectiveness of the resident's care, and it flows from each Resident's unique list of diagnoses. It should be organized according to the Resident's specific needs. The care plan is a means of communicating and organizing the actions and assuring the Resident's needs are attended to. The care plan is to be reviewed and revised at each assessment time of the Resident to ensure the interventions on the care plans are accurate and appropriate for the Resident. The findings include: 1) Resident # 13 was admitted to the facility on [DATE] and received long-term care, with a diagnosis of hemiplegia and hemiparesis…

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 the interview of the facility staff and review of the medical records, it was determined that the facility failed to provide needed care and services that are resident-centered, in accordance with the resident's goals for care and professional standards of practice that will meet each resident's physical needs. This was evident for one Resident (Resident #13) out of 44 residents reviewed for quality of care during the recertification/complaint survey. The findings include: Resident # 13 was admitted to the facility on [DATE] and received long-term care, with a diagnosis of hemiplegia and hemiparesis following cerebral infarction affecting the left side. On 03/10/25 at 10:55 AM, the surveyor observed Resident #13 with left arm contracture without any pillow or device in place to treat the contracture. On 03/14/25 at 11 AM medical record review revealed that Resident #13 had an order for a soft bolster for LEFT arm positioning r/t contracture. Gently place bolster between elbow and ribs for abduction and…

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 interview, staff interviews and medical record review, the facility failed to ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, recognition and management of Pain. This was evident for one resident (Resident # 35) out of two residents reviewed for pain management, during the recertification/Complaint survey. The findings include: On 03/12/25 at 09:42 AM, a medical record review of the Medication administration record (MAR) for January and February 2025 for Resident #35 revealed that Pain medication was administered without attempting to offer any nonpharmacological interventions. Further review of physician's orders revealed: - Acetaminophen Tablet 325 MG, Give 2 tablets by mouth every 8 hours as needed for Mild Pain 1-4, Order Dated 06/20/2024. - Non-pharmacological interventions were attempted prior to administering any PRN pain med. as needed. Document the number corresponding to the NonPharmacological Interventions attempted: 1. Warm…

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 review of the medical record and other pertinent documentation and interviews of facility staff, it was determined the facility failed to complete a thorough investigation when allegations of abuse and or misappropriation of property were reported by residents. This was found to be evident for 2 of 2 facility reported incidents effecting the following residents (Resident #57 and Resident #64) The findings include: 1. Review of the medical record for Resident #57 on 1/31/2020 revealed diagnosis including weakness, abnormalities of gait and mobility, generalized anxiety disorder and adjustment disorder. On 6/4/19, Resident #57 reported that s/he was missing $50.00. According to the facility investigation and facility report MD00141259, the business office confirmed that $50.00 was withdrawn from the residents account on 5/7/19 by the resident. The investigation also documented that the Business office also discussed with the resident any possible recent purchases and the resident agreed that there was still $34.50 unaccounted for. According to the facility investigation 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview with facility staff it was determined that the facility failed to timely assess a resident's nutritional status. This was evident during the initial review of 3 of 7 of residents (Resident #65, Resident #99, Resident #107). The findings include: 1. Review of the medical record for Resident #65 on 1/28/2020 at 2:22 PM revealed diagnosis including admission secondary to fracture and admission for rehabilitation. Further review of the resident's medial record revealed a documented weight on 12/16/2019 at 120 pounds (lbs.) and the current weight from 1/24/2020 as 110 lbs., a noted 8.33% weight loss. The resident's medical record revealed that a nutritional assessment was completed by the Registered dietitian (RD), #10 on 1/3/2020, 22 days after the resident's admission. The assessment noted that the resident had a fair appetite, a weight loss of 4%, an intake of 75-100%, a stage 1 pressure ulcer to the resident's sacrum and bilateral heels. A review of the resident's…

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 interviews with the facility staff it was determined the facility staff failed to store foods properly in the dry storage area. This was found to be evident during an initial tour of the facility conducted during the facility's annual survey. Findings include: An initial tour of the main kitchen was conducted on 1/27/20 at 8:25 AM with the Food Service Director (FSD) present. There were multiple food items stored on the shelf (not in the original box) that were not date labeled, and as follows: 32 oz lemon juice with 5 bottles not date labeled 1 box of coffee packets, not date labeled 17 boxes (24 packs in each box) of fudge rounds not date labeled 8 (1 pound) boxes of [NAME] Orzo not date labeled 1 (18 oz) container of Pepper not date labeled 1 (18 oz) container of [NAME] not date labeled 1 (18 oz) container of Cayenne Pepper, not date labeled During an interview with the FSD after the initial tour was completed, she was asked about the process by which foods are date labeled. 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.

Based on observation, interviews and medical record review, it was determined that the facility failed to ensure all staff followed contact precaution guidelines set by the facility by 1) wearing personal protective equipment (PPE) as directed and 2) properly cleaning equipment that goes from room to room of a resident diagnosed with a communicable disease. This was evident during tours of the facility throughout the annual survey, observations and interviews with the staff. The findings include: Personal protective equipment (PPE) acts as a barrier between infectious materials and skin, nose, mouth or eyes. This barrier has the potential to block the transmission of contaminants from blood, bodily fluids or respiratory secretions and to prevent the spreading of germs. They are used for infection control purposes, designated according to the resident's individual diagnosis and the route that the contaminant could be spread. 1. During the tour of the facility on 1/28/2020 at 11:36 AM, surveyor observed Staff #13 exiting a resident room, Resident #38, was identified as being 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.

Based on surveyor observation, resident and staff interviews, it was determined that the facility failed to maintain and enhance the dignity of the Resident # 19. This occurred in 1 of 7 sampled residents. The findings include: While interviewing the resident in the fifth-floor dining room during the resident council meeting on 1/29/20 at 11:00 am, and later in the day at 2:00 pm, the resident was noted with dried food particles on his/her wheelchair leg rests. On 2/3/20 at 11 am during a follow-up visit, the resident was again observed with the same dried food particle on his/her wheelchair footrests. During an interview with the resident at that time s/, he stated, my wheelchair is never washed. During an interview with the Director of Nursing on 2/3/20 at 1 pm, she states, the resident refuses to have his/her wheelchair washed. A review of the medical record did not reveal in the progress notes, or Care Plans that the resident refused to have his/her wheelchair washed. During an interview with the Administrator on 2/3/19, 1:30 pm she stated, the wheelchairs are scheduled to be…

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 it was determined that the facility staff failed to accurately code a resident's discharge from the facility. This was evident for 1 out of 1 residents (Resident #111) reviewed for discharges. The findings include: Review of the medical record on 1/31/2020 for Resident #111 for hospitalizations, revealed a discharge from the facility on 1/3/2020. Review of the Residents Minimum Data Set (MDS) assessments revealed a discharge MDS assessment completed 1/3/2020 documenting that the resident was discharged to the hospital. However, a review of the resident's paper chart and electronic nursing notes documented that the resident was discharged home. Interview with the MDS Coordinator #15, on 1/31/2020 at 12:44 PM revealed that the resident did go home and was not discharged to the hospital as was coded in section 'A' of the MDS and a correction would be completed.

Based on medical record review and interviews with the facility staff it was determined the facility failed to follow the care plan for a resident noted to be resistant to care. This was found to be evident when abuse allegations were reviewed for (Resident #64) during the facility's annual survey. Findings include: The investigation for facility reported incident MD00149497 was reviewed on 1/28/20. It revealed the family of Resident #64 reported that Geriatric Nursing Assistant (GNA) #26 was rude while providing care and told the resident, don't be resisting, you're hurting my back. Resident # 64 care plan was reviewed on 1/28/20 and it noted that the resident was resistive to care. Under interventions it indicated: if the resident becomes combative or resistive, postpone care/activity and allow time for him/her to regain composure. The Director of Nursing (DON) was interviewed on 1/28/20 at 2:55 PM and she was made aware of the concern of GNA #26 not following the care plan when the resident became resistive. The DON stated that the GNA's have been educated to stop 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 medical record review and interview with a resident and facility staff, it was determined the facility failed to update a care plan for a resident with a recent fall. This was evident for 1 of 6 residents (Resident #31) reviewed for falls during the survey. The findings include: Resident #31 was admitted with diagnoses that included Peripheral Vascular Disease, lack of coordination and Diabetes. A review of the Electronic Medical Record (EMR) on 1/28/20 at 10 AM revealed that on 1/10/20, the resident was found on the floor near his/her bed. S/he was assessed by the facility nursing staff, and no injuries were noted. Further review of the medical record revealed a physician ordered dated 6/27/18 for Non-Skid footwear for safety. Non-skid footwear has pliable soles with an intricate tread that helps to prevent slipping. Continued review of the medical record revealed a care plan dated 6/8/18 was in place for falls, however, Non-Skid footwear was not added as an intervention for safety. During an interview with Resident #31 on 1/28/20 s/he, stated: I was sitting on the edge…

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 the review of employee files and staff interview, it was determined that the facility failed to complete Geriatric Nurse Assistant (GNA) performance reviews annually. This was evident for 3 of 3 employee files reviewed (GNA #22, #23 and #24). The findings include: Review of the GNA employee files for GNA #22, #23 and #24 on 2/3/2020 at 11:15 AM, failed to reveal that an annual evaluation was completed for the identified staff. The Director of Nursing was interviewed on 2/3/2020 at 11:52 AM and she stated that she was aware annual assessments needed completed but did state that the annual competencies were in place. The concern that for the identified employees whose hire date varied from 2017-2018 who were chosen for review and who had been employed consistently at this facility for over 12 months had not had an individual performance review to verify their abilities was reviewed at that time.

Based on medical record review, interview with facility staff it was determined that the facility failed to: 1) monitor and assess the continued need for potassium for a resident (Resident #82) and 2) monitor a resident's blood pressure as ordered by the physician and administer an ordered medication (Resident #24). This was evident in the review of 2 of 5 residents (Resident #82 and Resident #24) reviewed during the investigative stage of the survey. The findings include: 1. Review of Resident #82's electronic medical record on 1/22/20 at 10 AM revealed the resident was admitted 12/2019 with the diagnoses that included hypokalemia, cognitive impairment, chronic kidney failure and atrial fibrillation. Review of the Medication Administration Record for December 2019 revealed the resident was admitted on Lasix 40 milligrams by mouth for edema. Lasix is a diuretic used to treat edema and swelling caused by congestive heart failure, kidney disease, and other medical conditions. According to the Medication Administration Record, the diuretic (Lasix) was discontinued on 12/31/19. A 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 medical record review and interview it was determined the facility staff failed to: 1) maintain the medical record in the most complete and accurate form for residents and 2) ensure Behavioral Health consultant progress notes were kept on the chart for other health care providers to review in a timely manner. This was evident for 2 of 8 residents (Resident #82 and Resident #38) reviewed during the annual survey. The findings include: Medical record documentation is a primary method ensuring communication of important clinical information between all shifts and amongst the interdisciplinary team members. Failing to ensure complete documentation in the resident's medical record increases the risk for adverse events related to communication failures between and amongst team members. A medical record is the official documentation for a healthcare organization. As such, it must be maintained in a manner that follows applicable regulations, accreditation standards, professional practice standards, and legal standards. All entries to the record should be legible and accurate. 1.…

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.