Autumn Court

Based on observation, staff interview, and review of the dishwasher manufacturer's guidelines, the facility failed to ensure the dishwasher washed and rinsed dishes at temperatures specified by the manufacturer's guidelines. This had the potential to affect all 48 residents who received food from the kitchen. The facility census was 48. Findings include: Observation on 10/16/24 at approximately 11:00 A.M. revealed the dishwasher labeled with Machine Operational Requirements with a wash temperature of 120 degrees Fahrenheit (F) minimum and a rinse temperature of 120 degrees F minimum. Further observation revealed Dietary Director (DD) #114 running one cycle of the dishwasher and the was temperature reached 80 degrees F during the wash and a rinse temperature of 88 degrees F. Concurrent interview with DD #114 revealed the dishwasher was a low-temperature machine and should wash and rinse at approximately 100 degrees F and 110 degrees F respectively. Two additional wash cycles were run, and the dishwasher temperatures peaked at a wash temperature of 88 degrees F and a rinse temperature…

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, resident interview, staff interview, and policy review, the facility failed to maintain a comfortable temperature throughout the facility. This affected 18 residents (#9, #10, #13, #15, #16, #17, #19, #22, #24, #29, #32, #33, #35, #36, #40, #42, #43, and #45) by the uncomfortable temperatures in the facility. Additionally the facility failed to maintain a clean and sanitary environment. This affected three residents (#8, #19, and #43) of 16 residents reviewed for environment. The facility census was 48. Findings include: 1. Observation and interview on 10/16/24 at 11:38 A.M. with Resident #33 revealed the heater not working or on at this time. Heater elements appear to be old and in disrepair. Cold air observed coming from the windows. Resident #33 stated his room was cold and he was cold last night. Resident #33 wanted his heater fixed. Interview and observation on 10/16/24 at 11:45 A.M. with Regional Director of Facility Management (RDFM) #156 confirmed their temperature gun showed a room temperature ranging from 60-65 degrees Fahrenheit (F) in Residents #33…

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 of medication administration, staff interview, and policy review, the facility failed to ensure the medication cart was secured at all times when unattended. This had the potential to affect all residents but three residents. The facility reported all residents were cognitively impaired and all but three residents were independently mobile or able to self-propel in a wheelchair. The facility census was 48. Findings include: Observation on 10/16/24 at 7:47 A.M. revealed Licensed Practical Nurse (LPN) #154 prepared medication at the medication cart which was parked adjacent to the dining room with the drawers facing away from the seating area. There was a half wall approximately two to two and one half feet high, between the cart and the actual dining room. During the observation, there were approximately ten to twelve residents in the surrounding area, with some residents arriving and departing breakfast service. After preparing medication for Resident #18, LPN #154 failed to lock the cart, walked away, and sat for approximately two minutes, in a chair next 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 observation, staff interview, and review of production recipes, the facility failed to ensure pureed foods were prepared properly. This affected one (#5) of one resident who received pureed food in the facility. The facility census was 48. Findings include: Observations beginning on 10/16/24 at 10:48 A.M. revealed [NAME] #109 receiving guidance from Dietary Director (DD) #114 regarding the preparation of one pureed portion of the noon meal. Interview with DD #114 revealed the noon meal consisted of beef pot roast, vegetable blend, mashed potatoes, and pumpkin pie. [NAME] #109 pureed and plated each food item separately. Observation of the pureed beef pot roast revealed a thick liquid with several small pieces of what appeared to be ground beef. Observation of the pureed vegetable blend appeared to be thin soup with several large pieces of vegetables. Observation on 10/16/24 at 11:55 A.M. revealed Resident #5 in the dining room received her noon meal tray with pureed items which included beef pot roast and vegetable blend. Interview and observation on 10/16/24 at 11:56 A.M.…

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, staff interview, medical record review, and review of policy for medication administration, the facility failed to practice appropriate hand hygiene during medication administration. This affected two residents (Residents #13 and #15) of three residents observed for medication administration. The facility census was 48. Findings include: Observation on 10/16/24 at 7:35 A.M. revealed Licensed Practical Nurse (LPN) #132 prepared 13 oral medications for Resident #13 by punching them from a punch card and/or removing them from a multi-dose container. During this preparation, LPN #132 touched each of the 13 tablets with bare skin while removing the medications from the packages and placing each them in the medication cup. LPN #132 then administered the medications to Resident #13. Observation on 10/16/24 at 7:41 A.M. revealed LPN #132 prepared six oral medications for Resident #15 by punching them from a punch card and/or removing them from a multi-dose container. During this preparation, LPN #132 touched each of the six tablets with bare skin while removing the…

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

Based on observations, resident and staff interview, review of the facility infection control log and review of the owner's manual for the chemical dishwasher, the facility failed to ensure dietary staff with skin conditions kept their arms properly covered and failed to ensure the chemical dishwashing machine maintained the appropriate level of chemicals for effective sanitation. This had the potential to affect all 49 residents residing in the facility. The facility census was 49. Findings include: 1. Observation on 07/05/22 at 8:51 A.M. of the kitchen found Dietary Staff (DS) #412 wearing a short sleeve black shirt. DS #412's arms were exposed and observed having flakey, white, scale like skin on both his right and left forearms. DS #412's right forearm was observed to have cracks with scabs and dried red areas between his elbow and his wrist as well as on the back of his right hand. DS #412 was observed preparing batter for pancakes and cooking pancakes on the stove. Interview on 07/05/22 at 9:33 A.M. with Resident #22 revealed the food was very good but the cook had some white…

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, resident and staff interview, medical record review, review of a facility investigation, review of self-reported incidents (SRI's), and review of a facility policy, the facility failed to report an injury of unknown origin to the State Survey Agency. This affected one (#38) of one residents reviewed for abuse. The census was 49. Findings include: Review of Resident #38's medical record revealed an admission date of 01/25/21. Diagnoses included schizoaffective disorder bipolar type, muscle weakness, anxiety, major depression, hyperlipidemia, unspecified psychosis, and unspecified dementia without behavioral disturbances. Review of the most recently completed Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #38 was assessed with severely impaired cognition, was assessed with physical behavioral symptoms directed towards others one to three days during the seven day look back period, and assessed with other behavioral symptoms not directed towards others (e.g.,…

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, medial record review, and resident and staff interview, the facility failed to develop a comprehensive care plan to include a resident's vagus nerve stimulator (VNS) used to treat seizures. This affected one (#29) of 15 residents reviewed for care plans. The facility census was 49. Findings include: Review of the medical record for Resident #29 revealed an admission date of 01/03/20 and a readmission date of 10/13/20. Diagnoses included chronic obstructive pulmonary disease (COPD), cerebral infarction (stroke), epilepsy, mild intellectual disability, major depressive disorder, anxiety disorder, and schizophrenia. Review of the quarterly Minimum Data Set (MDS) assessment, dated 06/21/22, revealed Resident #29 was cognitively intact, required supervision for ADL's, had a seizure disorder. Review of the plan of care, initiated 10/26/20, revealed Resident #29 was at risk for adverse effects and/or side effects from anticonvulsant therapy and had a diagnosis of epilepsy. The care plan for Resident #29's contained no documentation regarding the use of a VNS -…

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, observation, staff interview, and review of facility policy, the facility failed to ensure fall interventions were implemented as care planned. This affected one resident (#40) of two residents reviewed for falls. The facility census was 49. Findings include: Review of Resident #40's medical record revealed an admission date of 07/21/03. Diagnoses included dementia with behavioral disturbance, muscle weakness, abnormalities of gait, schizoaffective disorder, pseudobulbar affect, and epilepsy. Review of Resident #40's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of five out of 15 indicating Resident #40 was severely cognitively impaired. Resident #40 required extensive assistance with bed mobility, transfer, dressing, toilet use, and personal hygiene. Resident #40 displayed verbal behavioral symptoms directed toward others four to six days during the review period. Resident #40 had no falls since the last review. Review of Resident…

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 the resident council minutes, resident interview, staff interview and review of the facility policy, the facility failed to follow through on resident requests voiced during the resident council meetings. This had the potential to affect one (#39) of three residents who regularly attend resident council. The facility census was 45. Findings include: Review of the resident council minutes dated 08/28/18, under the old business section, revealed a request for a bench for outside had not been completed or approved. The residents would like a different view to give an opportunity to view wildlife. New business indicated Resident #39 would like to see a bench with higher seats out on the patio. Review of the resident council minutes dated 09/27/18 revealed no response from maintenance yet regarding the bench. Review of the resident council minutes dated 10/29/18 revealed, under the old business section, Maintenance Director (MM) #121 stated he had asked about building benches with higher seats. Review of the Resident/Family Council Response Form dated…

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, staff interview and facility policy review, the facility failed to ensure the advanced directives were accurately documented in the medical records. This affected three (#15, #17 and #28) of four residents reviewed for advanced directives. The facility census was 45. Findings include: 1. Review of the medical record of Resident #15 revealed an admission date of 01/07/19. Diagnoses included dementia without behavioral disturbances, restless leg syndrome and kyphosis to cervical region. Review of the quarterly Minimum Data Set (MDS) assessment ,dated 04/04/19, revealed the resident was cognitively intact. Review of the care plan initiated 01/14/19 indicated DPOA (durable power of attorney) has identified the advanced directive of Resident #15 as Do Not Resuscitate Comfort Care (DNRCC) - Arrest. Review of the form titled DNRCC, dated 02/01/19, indicated Resident #15's advanced directive as do not resuscitate comfort care arrest. The form described this as no life saving measures were to be performed in the event of a cardiac or respiratory arrest. Review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview and review of facility policy, the facility failed to refer three residents to be re-screened for pre-admission screening and resident review (PASARR) Level II services. This affected two (#2 and #17) of three residents reviewed for PASARR services. The facility census was 45. Finding include: 1. Medical record review for Resident #2 revealed the resident had been admitted to the facility on [DATE]. Diagnoses included schizoaffective disorder (10/15/12), cerebrovascular disease, general anxiety disorder (10/16/14), major depressive disorder (7/25/12) and impulse disorder (9/19/16). Review of the PASARR assessment, dated 09/21/11, reflected the resident had no indications of serious mental illness, and listed a diagnosis of depression only. The assessment tool had not been updated upon admission to reflect the current diagnoses at that time of schizoaffective disorder, general anxiety disorder, major depressive disorder and impulse disorder. Review of an annual…

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.