Advanced Rehab At Autumn Lake Healthcare

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of records, review of complaints and staff interviews, it was determined that the facility failed to 1) ensure narcotic record books were consistently signed by both incoming and outgoing nurses, 2) ensure that drug records were maintained in a manner that accounted for all controlled drugs and allowed for reconciliation of dispensed and administered medication, and 3) ensure that medication was administered in accordance with physician ordered parameters. This was evident for 8 of 8 medication carts observed during the medication storage task, 2 (Complaint #2646715, #2613978 ) of 5 complaints reviewed, and 1 (Resident #71) of 2 residents reviewed for pharmacy services during the annual survey. The findings include: The MDS (Minimum Data Set) is a federally mandated, standardized assessment tool used in Skilled Nursing Facilities (SNFs) to comprehensively assess a resident's clinical and functional status. The MDS is used to develop individualized care plans, monitor quality of care,…

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

Based on record review and interview, it was revealed that the facility failed to ensure the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNFABN) form was completed entirely. This was evident for 1 (Resident #26) out of 3 residents reviewed for beneficiary notification. The findings include: In a nursing home, beneficiary notifications are required notices given to residents or their representatives to inform them of changes in Medicare or Medicaid coverage, services or financial responsibility. These notices explain when covered services are ending, when services may not be covered, any potential costs to the resident, and the resident's right to appeal. Providing timely beneficiary notifications helps protect resident rights and ensures regulatory compliance. On 12/11/2025 at 10:12 AM, record review of the SNFABN document revealed that Resident #26's SNFABN form was incomplete. The section which asked the resident which option they would like regarding the billing of Medicare was left blank. On 12/11/2025 at 10:12 AM, an interview with Staff #7 revealed…

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 reviews, and interviews, it was determined that facility staff failed to establish infection control interventions to prevent the transmission of infection to residents. This deficient practice was evident for 3 (Resident #55, #3, and #95) of 5 residents reviewed for the infection control task during the annual survey. The findings include: On 12/04/2025, observations were made of Resident #3 at 9:07 AM, Resident #95 at 11:10 AM, and Resident #55 at 11:43 AM in their assigned rooms. During the observations, the surveyor noted that enhanced barrier precautions (EBP) signage was not posted on the residents' doors, and personal protective equipment (PPE) was not available outside of the residents' rooms. A review of Resident #3 medical record revealed an admission to the facility on [DATE], with multiple diagnosis, including orthopedic aftercare. The medical record included an order for daily wound dressing changes, however, further review failed to show an order for EBP. 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 administrative record review and interviews with facility staff, it was determined the facility failed to complete a thorough investigation and maintain documents regarding allegations of resident abuse. This was found to be evident for 4 (Resident #424, Resident #101, Resident #120, and Resident # 99) of 25 residents reviewed for abuse during the facility's survey. Findings include, 1. MD00190231 was reviewed on 6/17/24 at 12:30PM for allegations of abuse. The survey team requested a copy of the facility's investigation for the incident that occurred on 2/27/23 with Resident #424. On the same date at 1:30PM the Regional Nurse (Staff # 9) provided the survey team with a copy of the investigation and upon review, it included the following documents: a list of the resident's diagnosis, an initial 5-day report and a summary page. There were no interviews with residents or staff and no signed statements. The DON was interviewed on the same date at 1:45 PM and she was asked if the facility had any additional documentation of resident and staff interviews as part of their…

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 interviews with the resident and facility staff and record reviews, it was determined the facility failed to follow professional standards of nursing practice when administering medications to residents. This was found to be evident for 5 (Resident #60, #15, #502, and #509, #102) of 76 residents reviewed during the survey. The findings include: 1.) Resident # 60 was admitted with the following but not limited diagnosis: Chronic Pain An interview was conducted with Resident # 60 on 6/13/24 at 11:15 AM and the resident stated that s/he cannot get medications on time. The resident went on to say that s/he puts the call light on at 2:00 PM to receive PRN (as needed) oxycodone (a controlled medication used to treat moderate to severe pain) and the medication is not given until 4:00 PM, after the next shift comes on duty. The resident also stated that his/her scheduled medications are given late as well. The DON was made aware of the resident concerns on 6/13/24 at 1:45 PM and a request was made by the survey team for access via point click care electronic computer system 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 observations and staff interview, it was determined that the facility failed to treat each resident with dignity by not ensuring that residents' foley drainage bags were covered. This was evident for 2 (Resident #1 and Resident #504) of 5 residents reviewed for dignity. The findings include: A foley drainage bag, or urinary drainage bag, is a medical device used to collect urine from a catheterized patient. The drainage bag is usually worn on the leg or attached to a bed. During observation rounds on 6/12/24 at 7:50 am, Resident #1 was noted to have a foley catheter bag attached to their bed. The foley drainage bag was uncovered and had amber colored liquid. The bag was attached to the door side of the bed. Resident #1's door was open, and the foley drainage bag was visible from the hallway. On 6/12/24 at 7:54 am, the surveyor interviewed Unit Manager Licensed Practical Nurse (LPN) #6. When asked if residents with foley bags should have covers on the bags, LPN #6 stated foley bags should be covered and that she would ensure that the foley bags were covered. On 6/24/24 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, it was determined that the facility failed to ensure that a current copy of a resident's advance directive was in the resident's medical record. This was evident for 1 (Resident #512) of 5 residents reviewed for advanced directives. The findings include: During Record review on 6/13/24 at 1:45 PM, there was no record of an advance directive in Resident #512's electronic chart or paper chart. Based on medical records, the resident was admitted on [DATE]. On 6/13/24 at 2:15 PM, in an interview with the Director of Nursing (DON #17), DON #17 stated that the resident did have a Medical Orders for Life-Sustaining Treatment (MOLST) form created on 5/31/2024. DON #17 provided a copy of resident's MOLST form, which was signed by Doctor #31 on 5/31/2024. DON #17 stated the Doctor had completed the form and left the MOLST form on their desk instead of placing it in the paper chart or uploading it in the electronic chart. The MOLST form was not in Resident #512's chart for…

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

Based on record review and interview it was determined that the facility staff failed to notify the state agency of an alleged case of abuse within the 2-hour allotted timeframe and failed to report allegations of abuse to the state health department and to law enforcement. This was found to be evident for 2 (Resident # 83 and Resident #101) of 15 residents reviewed for abuse during the facility's survey. The findings include: 1. On 06/18/24 at 9:20 am surveyor received a copy of the facility's investigation of the facility reported incident MD00183880. Review of the self-report form revealed the alleged incident occurred on 09/25/22 during 3 pm to 11 pm shift. The alleged incident was reported to the state agency on 09/26/22 at 1 pm which was outside of the 2-hour allotted timeframe for reporting alleged abuse case. On 06/20/24 at 10:34 am a review of the facility's Abuse, Neglect, and Exhibition policy revealed under Section VII Reporting Abuse Reporting of all alleged violations to the Administrator, state agency, Adult Protective Services and to all other required agencies…

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 interviews, it was determined that the facility failed to provide to the resident a copy of the completed bed hold policy prior to transfer. This was evident for 1 (Resident #1) of 4 residents reviewed for transfer and discharge. The findings include: On 6/17/24 at 9:21 AM, a review of the medical records revealed the resident was sent to the hospital on 6/14/2024. A bed hold notice was identified in the resident's paper chart. The bed hold notice had not been completed and notes [resident's son] approved Bed hold policy via phone initialed KC on the side of the form. The resident's name was not on the bed hold notice nor any of the other fields completed on the form. According to the medical record, the resident was his/her own representative. On 6/17/24 at 2:05 pm, an interview was conducted with Licensed Practical Nurse (LPN) #23. LPN #23 was asked what is expected when notice of transfer is presented to a resident? LPN #23 responded, The resident or representative will sign the notice if they are capable. When asked if Resident #1 could sign 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 interview with the resident, review of medical records, and interview with facility staff, it was determined that the facility failed to provide a baseline care plan summary to residents. This was evident for 1 (#85) of 5 residents reviewed for baseline care plan summaries during the survey. The Findings Include: On 6/13/24 at 11:30AM, in an interview with Resident #85, they stated they have not been invited to a care plan meeting nor received a baseline care plan summary or baseline care plan. On 6/14/24 at 1:15 PM, review of the medical record did not reveal any evidence that Resident #85 was given a baseline care plan summary or a copy of a baseline care plan. On 6/21/24 at 10:37 AM, in an interview with the Director of Social Services (DSS) #2 she stated she did not have a baseline care plan for Resident #85. During the interview, she further stated that the nurses could not find a progress note or provide any additional documentation to show as evidence that Resident #85 was given a baseline care plan or baseline care plan summary.

Based on interview and medical record review, it was determined the facility failed to ensure comprehensive care plans were developed and implemented. This was found to be evident for 2 (Resident #112 and Resident #85) of 18 residents reviewed for care plans during the facility's survey. Findings include: 1. A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care they receive in a facility. It should describe the resident's goals and desired outcomes, the care/services that will be furnished, the resident's discharge plans, and refusals of care and action taken by facility staff to educate the resident. Review of Resident #112's medical record revealed the resident was admitted with the following but not limited diagnosis: Type 1 Diabetes Mellitus (a lifelong condition where the pancreas makes little or no insulin, which leads to high blood sugar levels). MD00203565 was reviewed on 6/25/24 at 4:00 PM for allegations of neglect in which Resident #112 reported not receiving insulin…

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 reviews and interviews the facility failed to provide ADL's (activities of daily living) such as showers according to the resident's preference. This was determined to be true for 1 (Resident # 44) out of 6 residents reviewed for ADL care during the survey. The findings include: At 2:50 PM on 06.18.24 the surveyor spoke with Resident #44 in his/her room. Resident was observed sitting in a wheelchair dressed in clean civilian clothes. The resident stated that s/he had recently moved from the first floor to the second floor within the last week. Resident #44 stated that he/she had received a shower only twice within the last month. This resident stated that her preference was to receive a shower twice per week. Additionally, the resident stated that he/she had discussed this concern with the unit manager and DON within the last month. On 06/20/24 at 01:56 PM Resident #44 stated that he/she was promised to receive a shower on Wednesday and Saturdays. Also, the Resident stated that he/she must be placed in a shower chair for the Geriatric Nursing Assistant (GNA) 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 observations, review of medical records, and interview with facility staff, it was determined that the facility failed to follow physician orders as evidenced by: 1) ensuring ordered ACE wraps were in place, 2) administering medication as ordered by the physician, and 3) a resident not receiving the ordered amount of oxygen. This was evident for 3 (Residents #40, #15, #37) of 9 residents reviewed during the survey. The findings include: 1) On 6/13/24 during initial tours of the facility and multiple surveyor observations of Resident #40 with the last observation of the day made at 2:12 PM, Resident #40 was observed without any ACE wraps in place anywhere on the resident. Medical record review for Resident #40 on 6/14/24 at 10:20 AM revealed multiple diagnosis including lymphedema, essential (primary) hypertension, pulmonary embolism, personal history of transient ischemic attack, atherosclerotic heart disease of native coronary artery, and chronic kidney disease, stage 4 (severe). Furthermore, Resident #40's physician orders were reviewed and noted the following, ACE wraps…

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 observations, review of the medical record, and interview with facility staff, it was determined the facility staff failed to provide residents with respiratory care consistent with professional standards by failing to ensure there was a physician order for oxygen administration/indication, failing to administer oxygen as prescribed, and failing to develop plans of care to address the resident's respiratory needs. This was evident for 1 (#85) of 3 residents reviewed for respiratory care during the investigation phase of the survey. The findings include: Oxygen flow meters are a relatively simple device that consist of a tube through which gas passes and a small, free-moving indicator such as a ball. When valves are open, the gas moves through the flow meter and causes the ball to float. A numbered scale on the tube along with the indicator allows the healthcare provider to determine the flow rate of oxygen. To ensure the most accurate reading of the flow rate, read the flow meter from a close distance, straight in front of the meter, and at eye level with 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 and interviews the facility failed to properly monitor medications. This was evident in 1 out of 4 medication storage rooms and carts during the survey. The findings include: During observation rounds on [DATE] at 03:05 PM the following was found in the 1st floor Unit 2 medication room: 1 expired Influenza Vaccine Afluria Quadrivalent 5ml Multi-dose Vial with an expiration date of [DATE]. During an interview and observation round of the 1st floor Unit 2 medication room with Unit Manager staff #6 on [DATE] at 03:15 PM, staff #6 stated and confirmed that there was 1 expired Influenza Vaccine Afluria Quadrivalent 5ml Multi-dose Vial.

Based on interviews and medical record reviews it was determined that the facility staff failed to schedule a dental appointment and arrange transportation to and from the dental appointment. This deficient practice was evident for 1 (#37) of 1 resident record reviewed for dental care during the survey. The findings include: On 06/13/24 at 9:28 am, during an interview with Resident #37, he/she reported that his/her bottom dentures were lost. He/she could not recall which staff member he/she reported the incident to, or the exact month it occurred. Review of the resident's personal belongs log in Point Click Care (PCC) revealed there was no documentation of the resident having dentures upon admission to the facility. The resident reported difficulty eating without having bottom dentures. During an interview with Director of Nursing (DON) #17 on 06/17/24 at 12:23 pm, the DON reported all resident's belongings are logged into PCC under the evaluation tabs at the time of admission, discharge, and readmissions. DON #17 explained that a grievance form would be completed for all reported…

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

Based on record review and interview with facility staff, it was determined the facility failed to provide documentation whether a resident had signs and symptoms of abuse immediately following an allegation of abuse and failed to provide documentation to verify monthly pharmacy review was completed in 2024. This was evident for 3 (#508, #11, #21) of 15 residents reviewed during the survey. The findings include: 1) Review of the facility's Abuse, Neglect and Exploitation Policy on 6/25/24 at 3:01 PM revealed in the Investigation of Alleged Abuse, Neglect and Exploitation section, Written procedures for investigations include: Focusing the investigation on determining if abuse, neglect, exploitation and/or mistreatment has occurred, the extent, and cause; and Providing complete and thorough documentation of the investigation. Further review of the policy in the Protection of Resident section, Examining the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed . Resident #508's medical record was reviewed on 6/26/24 at 11:22 AM.…

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, medical record review and interview with facility staff, it was revealed the facility failed to administer medications as ordered by the physician. This was evident for 1 of 1 (Resident #1) reviewed during the complaint survey. The findings include: Medical record review on 1/10/24 at 9am revealed that Resident #1's diagnoses included but were not limited to Dementia, Anxiety, high blood pressure, Depression and Multiple Sclerosis. According to the hospital discharge Resident #1 was admitted in October of 2022 for Physical and Occupational Therapy Rehabilitation. Review of resident #1's medical record on 1/10/24 at 2pm revealed the following: 1. On 10/3/2022 a physician ordered resident #1 to receive Amlodipine 10 mg(milligrams) at 10am every day by mouth for high blood pressure. 2. On 5/17/23 a physician ordered resident #1 to receive Seroquel 25mg at 10am every day by mouth for depression. 3. On 9/8/2023 a physician ordered resident #1 to receive Meloxicam 15mg everyday at 12noon by mouth for joint pain. Review of the MAR (Medication Administration Record)…

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 reviews of administrative records and staff interview, it was determined that the nursing administrative staff failed to conduct a yearly performance review on 2 of 6 geriatric nursing assistants for the prior 12 months. The findings include: On 08/28/19, a review of 6 random geriatric nursing assistant (GNA) for yearly performance appraisal revealed that 2 of the 6 GNA's had not had a yearly appraisal in the previous 12 months. Review of GNA #3's records revealed GNA #3's last performance appraisal was conducted on 08/14/2010. Review of GNA #1's records revealed that GNA #1's last performance appraisal was 08/20/2013. In an interview with the Director of Nursing (DON) on 08/29/19 at 12:25 PM, the facility DON confirmed that GNA #1 and GNA #3 were not given a performance appraisal for the past 12 months.

Based on observation of medication pass and interview, it was determined the facility staff failed to obtain a medication error rate less than 5% (Resident #286). This includes 1 out of 3 residents observed for medication pass, 2 errors out of 25 opportunities with a medication error rate of 8%. The findings include: The facility uses an Electronic Medical Record (EMR) for the administration and documentation of medications for administration to the residents. The physician's orders for the medications are entered in the EMR with the times of medication administration. The Five Rights of Medication Administration. One of the recommendations to reduce medication errors and harm is to use the five rights: the right patient, the right drug, the right dose, the right route, and the right time. 1. The facility staff #21 failed to administer medication to Resident # 286 as ordered by the physician. Medical record review for Resident #286 revealed the physician ordered: Prednisone 1 mg tablets, give 2 tablets po every day. Prednisone is used as an anti-inflammatory or an immunosuppressant…

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, it was determined the facility staff failed to ensure medications were thoroughly labeled with residents' name and dated when the medication were open. This was evident for 2 of 4 medication carts observed during the annual survey process. The findings include: Observation of the medication cart on 08/30/19 at 8:16 AM revealed the following observation: 1. The medication cart 1 on Unit 1 had the following: insulin medications with no open dates, Humalog, Novolog and two Basaglar pens. 2. The medication cart on Unit 2 had the following: brimonidine eye drops with no open date, Plavix with no name and Ipratropium nasal spray with no open date. Interview with the Director of Nursing on 08/30/19 8:30 AM confirmed the facility staff failed to ensure medications were thoroughly labeled with residents' name and dated when open.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews with staff it was determined that the facility failed to ensure residents had a means of directly contacting staff. This was evident for 3 pull chords in 2 resident spa rooms. The findings include: On 8/28/2019 at 8:09 AM the spa room across from room [ROOM NUMBER] was observed to have the call light in the shower suspended between the wall unit and the escutcheon plate for the shower's grab bar. This caused the pull chord to be suspended approximately 30 from the ground and not easily accessible to a resident should they fall. The toilet room within this spa room was observed with the call light chord wrapped around the grab bar preventing the alarm from activating when the chord was pulled. At 8:25 AM observation of the spa room across from room [ROOM NUMBER] revealed the pull chord in the first shower on the left was also wrapped around the grab bar preventing it from functioning properly. These findings were reported immediately to GNA #8. The Administrator and Director…

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.