Autumn Lake Healthcare At Long View

Based on interview, and pertinent documentation review, it was determined that the facility failed to communicate to staff that a resident had dentures and failed to take reasonable precautions to prevent a resident's dentures from getting lost. This was evident for 1 Resident (Resident #77) out of 3 residents investigated for personal property, during a survey. The findings include: On 4/10/24, a review of records revealed Resident #77 was a long-term resident of the facility. On 4/10/24 at 8:20 AM, Resident #77's family member was interviewed. During the interview s/he reported that Resident #77 had dentures when s/he was admitted to the facility, but the dentures were lost during the residents stay. On 4/16/24 at 1:40 PM, a review of Admission/Readmit Screener document, dated 6/16 23, revealed that the resident was admitted to the facility with partial lower dentures that s/he wore only when eating. Further review of the document revealed that Resident #77 required the facility staff to assist him/her with both setup and clean up assistance when performing oral hygiene. 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 staff interviews and the review of the facility records, it was determined that the facility failed to monitor and prevent the misappropriation of resident property. This was evident for 1 ( Resident #153) out of 16 residents reviewed for abuse during the annual survey. The findings include: Resident #153 was readmitted to the facility and received long-term care for more than three years. Part of the resident's care was pain management. There was an order to receive Oxycodone 10mg three times a day during the month of May 2023. The facility reported an incident of missing medication (Oxycodone) on 05/12/2023. On 04/17/24 at 10:23 AM, a review of the facility's report on the incident revealed that the narcotic medication (Oxycodone) card with 30 pills was received from the Pharmacy on 05/08/23 and that on 5/11/23 it was discovered that this card, with approximately 23 remaining pills, was missing. A review of Nurses' statements, interviews, resident interviews, review of medication administration records (MAR) and narcotic records indicated that the agency Nurses counted…

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 records review and interviews, the facility failed to provide the resident and/or resident's representative with the notice of transfer in writing as soon as practicable. This was evident for 2 (Resident #86, #85) of 4 residents reviewed for hospitalization. The findings include: 1) Resident #86 was admitted to the facility in 2023. The resident's medical record indicated that s/he was recently sent to the hospital for an evaluation due to a change in condition. On 4/11/24 at 11:26 AM, the change in condition/concurrent review form for Resident #86, initiated by Licensed Practical Nurse (LPN Staff #37) with an effective date of 4/7/24 at 12:30 AM, was reviewed and revealed section P (Documentation provided for residents/resident representatives) with 5 items for the staff to mark. The first 2 items were listed under THE FOLLOWING ITEMS MUST BE GIVEN TO RESIDENT UPON HOSPITAL TRANSFER, where item 1. Documents Given to Resident, had an area for reason for transfer/discharge that was blank, and item 2. Resident is their own responsible party had the area marked as no. The next…

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 records review and interviews, the facility failed to provide the resident and the resident's representative with the notice of bed-hold policy in writing. This was evident for 2 (Resident #86, #85) of 4 residents reviewed for hospitalization. The findings include: 1) Resident #86 was admitted to the facility in 2023. The resident's medical record indicated that s/he was recently sent to the hospital for evaluation due to a change in condition. On 4/11/24 at 11:26 AM, the change in condition/concurrent review form for Resident #86, initiated by Licensed Practical Nurse (LPN Staff #37) with an effective date of 4/7/24 at 12:30 AM, was reviewed and revealed section P (Documentation provided for residents/resident representatives) indicated that the bed hold policy was provided to the resident and the resident representative. Later at 1:18 PM, the Admissions Director (Staff #38) was interviewed about the recent transfer of Resident #86. Staff #38 reported that she sent the bed hold policy via email to the RP and would give the surveyor a printout of the email as evidence. 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 staff interview, it was determined that the facility staff failed to complete, within 14 days, a Significant Change in Status Minimum Data Set (MDS) Assessment. This was evident for 1 (#4) of 1 residents reviewed for hospice during the survey. The 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. Information collected drives resident care planning decisions. MDS assessments must be accurate to ensure each resident receives the necessary care. A significant change means a major decline or improvement in a resident's status that will not normally resolve itself without further intervention by staff or by implementing standard disease-related clinical interventions that have an impact on more than one area of the residents' health status. When there is a major decline or lack of improvement in a resident's status, a MDS Significant Change in Status Assessment (SCSA) should be completed within 24 days. On 4/17/24 at 9:01 AM, 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 record review and staff interviews, it was determined that the facility failed to complete comprehensive Minimum Data Set (MDS) assessments within the regulatory time frames to facilitate appropriate care planning and maintain current and accurate assessment records. This was evident for 7 (#29, #52, #72, #11, #96, #92, #37) of 68 residents reviewed during the recertification survey. The findings include: The MDS is a federally mandated assessment tool that nursing home staff use to gather information on each resident's strengths and needs. The information collected drives resident care planning decisions. The admission MDS assessment is a comprehensive assessment for new residents and, under some circumstances, returning residents. It must be completed by the end of day 14, counting the date of admission to the facility as day 1. The Annual MDS assessment is a comprehensive assessment for a resident that must be completed annually (at least every 366 days) unless a Significant Change in Assessment has…

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 pertinent document review and interviews, it was determined that the facility failed to document that incontinent care was provided to a dependent resident. This was evident for 1 (resident # 298) out of 2 residents, reviewed for neglect during a survey. The findings include: Review of intake # MD00176574 revealed a concern that Resident #298, a long-term care resident, was not receiving appropriate incontinent care. On 4/18/24 at 6:17 AM, review of the quarterly Minimum Date Set (MDS) dated [DATE] section G0400, revealed that resident #298 was dependent on the staff for toileting hygiene. Further review of section H under urinary continence revealed that Resident #298 was documented as being always incontinent. The Minimum Data Set (MDS) is part of the process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes. This process provides a comprehensive assessment of each resident's functional capabilities and helps nursing home staff identify health problems. 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 interviews, and medical records review, it was determined that the facility failed to provide treatment and care in accordance with professional standards of practice. This was evident for 1 (Resident #1) out of 4 residents who were reviewed for hospitalization during the annual survey. The findings include: Resident #1 has been at the facility for more than two years. The resident was diagnosed with Diabetes Mellitus along with other medical conditions. On 04/10/24 at 10:03 AM, an interview revealed that the resident was sent to the hospital about a month ago. The resident also reported that s/he was not getting insulin before going to the hospital but was now receiving it. On 04/12/24 at 11:24 AM, a record review confirmed the resident's report that s/he was not receiving insulin prior to the recent hospitalization. Further review revealed that, on 02/14/24 at 1:08 PM, the facility received a lab report revealing a glucose level of 328 mg/dl. Provider #3 saw the Resident on the same day, 02/14/24, 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.

Based on records review and interviews, it was determined that the facility failed to ensure that a resident's drug regimen was free from unnecessary drugs and failed to notify a resident's attending provider of when a medication was not given. This was evident for 3 (Resident #198, #4, #85) of 6 residents reviewed for unnecessary medications and 1 (#85) of 68 residents reviewed during hte recertification survey. The findings include: 1) Resident #198 was admitted to the facility in 2023 and was sent to the emergency room after 7 days for a change in condition. On 4/12/24 at 12:50 PM, Resident #198's progress notes were reviewed and revealed a note documented by Licensed Practical Nurse (LPN Staff #35) on 7/24/23 at 8:30 PM that indicated she had administered medication for an acute onset of pain. On the same day at 1:20 PM, Residents #198's medical records were reviewed and revealed pain management orders including: a) Oxycodone HCl Oral Tablet 5 MG, give 1 tablet by mouth every 4 hours as needed for pain scale 5-10 related to a left femur fracture. Oxycodone is a potent opioid…

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 interviews, staff interviews, and medical record reviews, it was determined that the facility failed to implement individualized, non-pharmacological approaches to care prior to the use of psychotropics. This was evident for 1 (Resident #1) out of 1 resident reviewed for mood and behavior. The findings include: Resident #1 has been at the facility for more than two years, receiving long-term care. The resident was diagnosed with multiple medical conditions. On 04/11/24 at 11:45 AM, a medical record review revealed that the resident was seen by a psychiatric provider on 12/10/23, who stated that the Resident denied having Anxiety or depression. A review of Nurses' progress notes from 03/22/24 to 03/31/24 revealed no documentation of the resident being awake at night. On 3/25/24 at 1:00 PM, the Nurse Practitioner's (NP Staff #41)) progress notes stated that the resident was more interactive than what I'm used to though staff reports that the resident was at [his/her] baseline. On 03/31/24 at 3:25 AM, Nurse progress notes stated, slept well, call light within reach.…

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, it was determined that the facility failed to properly store medication as evidenced by failing to discard expired medications and failing to date medications when opened. This was evident for 3 or 3 medication carts observed during the survey. The findings include: 1) On 4/19/24 at approximately 2:55 PM, an observation of a medication cart on Unit 1A revealed an open bottle of Promethazine DM Oral solution that was labeled with Resident #3's name, a 1/2/24 opened date and a manufacturer expiration date of 1/24. The facility failed to discard the bottle of Promethazine when it expired in January 2024. Also, in the Unit 1A medication cart, there was a Trelegy Ellipta inhaler that was labeled with Resident #80's name and the opened date was 2/27/24. According to the manufacturer's instructions, Trelegy Ellipta inhaler should be discarded after the foil tray is opened or when the counter reads 0, whichever comes first. The Trelegy inhaler should have been discarded on 4/9/24, which was 6 weeks after opening. On 4/19/24 at 3:22 PM, At that time,…

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 records review and staff interviews, it was determined that the facility failed to keep complete and accurate medical records. This was evident for 1 (Resident #16) of 16 residents reviewed for abuse, and 1 (Resident #64) of 6 residents reviewed for unnecessary medications. The findings include: 1) 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. Information collected drives resident care planning decisions. On 4/10/24 at 9:58 AM, a medical record review showed that Resident #16 was admitted to the facility in March 2022. Continued review revealed an MDS assessment, dated 3/8/22, that documented Resident #16 used hearing aids. On the same day at 10:20 AM, a record review for Resident #16 revealed an order summary report for April 2024 that contained an attending provider's order, initiated on 6/12/2022, for the Nurse to apply hearings aids upon rising and remove at HS. To be locked in treatment cart when not in use for safekeeping every day and evening shift (HS - 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 observations, records review, and interviews, it was determined that the facility failed to replace and store a nebulizer mask in a sanitary manner to prevent the spread of infection, failed to post notification requiring the use of personal protective equipment (PPE), and failed to wear the proper PPE prior to entering a room which required enhanced barrier precautions (EBH). This was evident for 2 (Resident #28, #38) of 3 residents reviewed for respiratory care and 2 (Resident #85, #1) random observations during the survey. The findings include: 1) A nebulizer is a small machine that turns liquid medicine into a mist to be inhaled through a mouthpiece or mask and enters the lungs directly. After use, the mask or mouthpiece is washed with mild soap, rinsed under running water, dried on paper, and kept in a sealable plastic bag. During a tour of the 2nd-floor unit on 4/9/24 at 10:46 AM, Resident #28 was observed lying in bed and wearing oxygen through nasal cannula tubing attached to an oxygen…

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 resident council representatives and staff, it was determined the facility staff failed to reply to the resident council in response to grievances or concerns in a timely manner. This was evident for 4 of 4 residents present as resident council representatives (Residents #50, #22, #45 and #255). The findings include: 1 A. The facility staff failed to respond to the resident council in a timely manner in reference to inquiry about the shingles vaccine. Surveyor interview with Residents #50, #22, #45 and #255 as representatives of the resident council on 4/24/19 at 10:30 AM revealed the facility staff failed to respond to the resident council in a timely manner in response to concerns or grievances. Review of the resident council minutes for 10/15/18 revealed that residents requested to contact facility staff #7, the infection control nurse to inquiry about the shingles vaccine (chicken pox). It was revealed, the vaccine was on back order and the facility did not have access to the vaccine and facility staff #7 would get back to the residents. Upon interview…

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 complaint, reviews of a closed record, and staff interview, it was determined the facility staff failed to notify residents and/or representative of transfer and reason for transfer to the hospital in writing. This was evident for 1 (Resident #26) of 4 residents reviewed for Hospitalization during an annual recertification survey. The findings include: 1. Review of the medical record for Resident #26 revealed the resident was transferred to an acute care facility on 1/9/2019. There was no documentation found in the medical record that the resident, and or the resident's responsible party was given written notice of Resident #26 being transferred to the hospital and the reason for the transfer to the hospital. On 4/23/19 at 1: 30 PM the Chief Corporate Nurse stated that the resident and or resident's responsible party did not receive written notice as to why the residents was being transferred to the hospital and the reason for the transfer to the hospital.

Based on review of the medical record and staff interview, it was determined the facility staff failed to provide the resident and their representative with a written notice of bed hold policy, at the time of the resident transfer for hospitalization. This was evident for 1 (Resident #26) of 4 residents reviewed for Hospitalization during an annual recertification survey. The findings include: 1. Review of the medical record for Resident #26 revealed the resident was transferred to an acute care facility on 1/9/2019 and returned to the facility on 1/11/2019. There was no documentation found in the medical record that the resident or the resident's responsible party was given a copy of the bed hold policy upon transfer to the hospital. On 4/23/19 at 1:00 PM, the Chief Corporate Nurse confirmed that the Residents and or the Resident's responsible party did not receive the facility bed hold policy when transferred to the hospital.

Based on clinical record review it was determined that the facility staff failed to ensure resident assessments were accurate (#78). This was evident for 1 out of 2 residents selected for choices. The findings are: The MDS is a federally-mandated assessment tool that helps nursing home staff gathers information on each resident's strengths and needs. Information collected drives resident care planning decisions. MDS assessments need to be accurate to ensure each resident receives the care they need. Categories of MDS (Minimum Data Set) are: Cognitive patterns, Communication and hearing patterns, Vision patterns, Physical functioning and structural problems which includes the assessment of range of motion, Continence, Psychosocial well-being, Mood and behavior patterns, Activity pursuit patterns, Disease diagnosis, Other health conditions, Oral/nutritional status, Oral/dental status, Skin condition, Medication use and Treatments and procedures. At the end of the MDS assessment the interdisciplinary team develops the plan of care for the resident to obtain the optimal care for 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 review of medical record and staff interview, it was determined the facility staff failed to develop a comprehensive care plan for Resident (#26) and failed to follow an established comprehensive care plan addressing identified behavior for a resident (#25). This was evident for 2 of 47 residents selected for review during the survey process and review of care plans. The findings include: A comprehensive care plan is an outline of nursing care showing all the resident's needs and the ways of meeting the needs. It is a dynamic document initiated at admission and subject to continuous reassessment and change by the nursing staff caring for the patient. The care plan typically includes nursing and medical diagnoses, nursing interventions, and outcomes to ensure consistency of care. 1. Medical record review for Resident #26 revealed the resident had a history of frequent joint pain. The physician ordered: On 2/18/2019 Tramadol HCL tablet 50 milligrams (mgs.) administer 1 tablet by mouth every six hours as needed for pain. Tramadol is used to relieve moderate to moderately…

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 provide care to Resident (#25) in order to obtain or maintain optimal level of well-being. This was evident for 1 of 47 residents selected for review of quality of care during the annual survey. The findings include: 1. The facility staff failed to administer a medications Alendronate as ordered by the physician and recommended by the pharmacist. Medical record review for Resident #25 revealed on 3/15/19 the pharmacist recommended that Alendronate is to be administered on an empty stomach with 6-8 ounces of water, at least 30 minutes before the first food, drink, or other medications of the day. Alendronate is a medication to prevent and treat certain types of osteoporosis (bone loss) in adults. On 3/20/19 the physician agreed to the pharmacist recommendation. Review of the Medication Administration Record revealed the facility staff failed to administer Alendronate as ordered by the Physician. Review of nurses' documentation revealed the facility staff documented the medication was given 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 medical record review, observation and interview, it was determined the facility staff failed to provide Resident (#3) with a lid on the coffee mug as ordered by the physician. This was evident for 1 of 6 residents selected for review of nutrition care area and 1 of 47 residents selected for review during the annual survey process. The findings include: Medical record review for Resident #3 revealed on 2/7/19 the physician ordered: drinks in coffee mugs with lids, no straws. Surveyor observation of Resident #3 on 4/24/19 at 12:30 PM revealed the resident out of bed eating lunch. The facility staff provided the resident with liquids in coffee mugs; however, the facility staff failed to apply lids. It was noted at that time, Resident #3 had 3 coffee mugs with liquids; however, none of the mugs had lids on as ordered by the physician. Interview with the Director of Nursing on 4/25/19 at 1:30 PM confirmed the facility staff failed to provide Resident #3 with coffee mugs with lids as ordered by the physician.