Autumn Aegis Nursing Home

Inspectors wroteBased on observation and staff interview, the facility failed to maintain a clean, sanitary, and safe environment. This had the potential to affect all 86 residents. The facility census was 86. Findings Include: Observation of the facility environment on 05/02/24 between 9:30 A.M. and 10:00 A.M., with Maintenance Director (MD) #210, revealed the carpeting throughout common areas, hallways, and resident rooms showed significant instances of large stains. Further observation of the common areas of the facility revealed the handrails in the common hallways were observed to be discolored and rough to the touch in numerous areas. There were numerous instances of dead bugs noted in light fixtures throughout the facility including in resident dining areas. There were numerous water-stained ceiling tiles noted around the 100 hall nurse's station. [...]

Inspectors wroteBased on medical record review, review of a care conference audit tool, resident and resident representative interview, staff interview, and review of a facility policy, the facility failed to conducted care conferences quarterly and with a significant change in condition as required. This affected five (#25, #32, #36, #62, and #64) of six residents reviewed for care planning meetings. The facility census was 86.

Inspectors wroteBased on review of banking records and staff interview, the facility failed to notify residents when their resident funds accounts were within $200.00 of the Medicaid resource limit as required. This affected four (#12, #60, #65, and #79) of five residents reviewed for personal funds. The facility census was 86.

Inspectors wroteBased on medical record review, resident and staff interview, and review of the Resident Assessment Instrument (RAI) manual, the facility failed to code resident Minimum Data Set (MDS) assessments accurately. This affected five (#53, #60, #78, #47, and #64) 18 sampled residents reviewed for accuracy of MDS assessments. The facility census was 86. Findings Include: 1. Review of the medical record revealed Resident #53 was admitted to the facility on [DATE] with diagnoses that included unspecified intellectual disabilities, seizures, and unspecified delirium. Review of the Pre-admission Screening and Resident Review (PASRR) Level Two evaluation from the state department of developmental disabilities dated [DATE] revealed Resident #53 had a level two developmental disability. [...]

Inspectors wroteBased on medical record review, resident and staff interview, and policy review, the facility failed to ensure resident care plans were updated to reflect individualized and necessary components of their care. This affected two (#47 and #64) of 22 residents reviewed for care planning. The facility census was 86.

Inspectors wroteBased on observation, staff interview, medical record review, review of an air mattress operation manual, and policy review, the facility failed to ensure interventions were in place to treat existing pressure ulcers and prevent new pressure ulcers from developing as ordered. This affected one (#64) of two residents reviewed for pressure ulcers. The facility census was 86.

Inspectors wroteBased on medical record review, review of a list of residents who smoke, resident and staff interview, and review of a facility policy, the facility failed to complete smoking assessments as required. This affected one (#25) of three residents reviewed for smoking. The facility census was 86.

Inspectors wroteBased on observation, resident and staff interview, and medical record review, the facility failed to offer and provide dental services for residents with dentures. This affected one (#36) of three residents reviewed for ancillary services. The facility census was 86.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure required information was posted and updated as required. This affected all 86 residents residing in the facility. The facility census was 86.

Inspectors wroteBased on observation, review of survey history, and staff interview, the facility failed to make reports of complaint investigations during the three pervious years readily available as required. This had the potential to affect all 86 residents currently residing in the facility. The facility census was 86. Findings Include: Observation on 04/30/24 at 8:00 A.M. of the facility's main entrance and common area revealed no readily available survey book. The survey book was located by a state surveyor in a closed drawer of a nightstand, not publicly visible, near the front entrance with no recent surveys observed. Review of previous survey activity for the facility revealed the Ohio Department of Health conducted complaint investigation surveys on 05/04/22, 09/12/22, 12/09/22, 01/05/23, 02/17/23, 05/08/23, 09/28/23, and 03/01/24. [...]

Inspectors wroteBased on observation, record review, policy review and staff interview, the facility failed to ensure proper portion sizes were served to residents that received pureed consistency meal items. This had the potential to affect 13 (#7, #11, #18, #20, #34, #38, #39, #40, #42, #43, #318, #319, and #320) of 13 residents, who were prescribed a pureed diet. The facility census was 74.

Inspectors wroteBased on observation, staff interview and policy review, the facility failed to serve pureed foods at a smooth consistency for safe swallowing. This had the potential to affect 13 (#7, #11, #18, #20, #34, #38, #39, #40, #42, #43, #318, #319, and #320) of 13 residents, who were prescribed a pureed diet. The facility census was 74.

Inspectors wroteBased on medical record review, resident and staff interview and review of facility policy, the facility failed to ensure residents were given the opportunity to participate in the care planning process. This affected three (#61, #57, #46) of 22 residents reviewed for care planning. The facility census was 74.

Inspectors wroteBased on observation, record review, and resident and staff interview, the facility failed to ensure physician's orders were in place prior to implementing dressing changes. This affected one (#64) out of two residents reviewed for dressing changes. The facility census was 74.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure the Minimum Data Set (MDS) assessments were accurate to reflect the residents condition regarding infections, injections and insulin, the discharge disposition and the level of assistance required for transfers. This affected four (#84, 190.90, and #39) of 23 records reviewed for assessments.

Inspectors wroteBased on observations, review of the manufacturers recommendation and staff interview, the facility failed to store medications in the original packaging provided by the manufacturer or pharmacy and according to the manufacturer's directions. This had the potential to affect 15 (#24, #39, #40, #48, #66, #80, #85, #86, #188, #189, #190, #191, #290, #291, and #292) residents who had been admitted to the facility in the previous 30 days. The facility census was 90.

Inspectors wroteBased on record review, observations, staff interview, and review of a facility policy, the facility failed to treat residents in a dignified manor when urinary catheter drainage bags were not being covered. This affected two (#291 and #26) of two residents reviewed for dignity. The facility identified 10 residents with urinary catheters. The facility census was 90.

Inspectors wroteBased on observation, medical record review and staff interview, the facility failed to implement pressure relieving devices for a resident with a pressure sore. This affected one (#84) of two resident reviewed for pressure sores. The facility census was 90.

Inspectors wroteBased on medical record review and staff interview, the facility failed to clarify fluid restriction orders for one resident. This affected one (#84) of two resident reviewed for fluid restrictions. The facility census was 90.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure one resident had a indication for use prior to administering an as needed antipsychotic medication. This affected one (#72) of five residents reviewed for unnecessary medication. The facility census was 90. Findings Include: Review of the record for Resident #72 revealed the resident was admitted to the facility on [DATE]. Diagnoses included dementia with behavioral disturbance, difficulty talking after having a stroke, heart disease, and glaucoma. Review of the comprehensive 30 day Minimum Data Set (MDS) assessment dated [DATE], revealed the resident was severely cognitively impaired, required extensive assistance for personal care, and received an as needed antipsychotic medication two of the seven day assessment period. [...]

Inspectors wroteBased on record review, observations, staff interview and review of a facility policy, the facility failed to ensure staff performed appropriate hand hygiene while performing a dressing change. This affected one resident (#58) of two resident's reviewed for pressure ulcers. The facility census was 90.