Autumn Lake Healthcare at Arlington West

Inspectors wroteBased on interview, and record review, it was determined that the facility failed to assist a Resident to receive proper treatment to maintain vision. This was found evident of 1 (Resident #15) out of 1 Residents reviewed for hearing and vision during an annual survey.

Inspectors wroteBased on observations, review of medical records, facility investigative file, and interviews it was determined that the facility failed to implement interventions, determined to be necessary, for residents who were dependent and identified as fall risks. This was evident for 3 (Resident #9, #8 and #48) out of 4 residents reviewed for accidents.

Inspectors wroteBased on observations, interviews, and record review, it was determined that the facility failed to obtain and administer medications according to a Resident's medication regimen and ensure that pharmaceutical services included the removal of expired medications and the safe handling of medications. This was evident for 1 resident (Resident #48) out of 7 reviewed for medications and 2 (2nd floor) of 4 medication carts during medication administration facility task observation.

Inspectors wroteBased on record review, observations, interview with resident and staff, the facility failed to ensure a clean, comfortable and homelike environment. This is evident for 1 (resident #66 ) out of 1 resident reviewed during the survey.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure a resident was free from abuse. This was evident for 1 (Resident #74) out of 5 residents reviewed for abuse during the facility's recertification survey.

Inspectors wroteBased on record review and interview it was determined the facility failed to ensure the timeliness of reporting of an allegation of abuse. This was evident for 1 (Resident #17) out of 5 residents reviewed for abuse (MD00205138) during the facility's recertification survey.

Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to ensure that a resident's medication preparation was in accordance with the physician's order for the prescribed dosage amount. This was evident for 1 out of 25 medication administrations observed by the surveyor during the review for medication administration during the facility's recertification survey.

Inspectors wroteBased on observation, interview, and documentation review it was determined that the facility staff failed to store, prepare, and maintain a sanitary environment in accordance with professional standards for food service safety by failing to ensure dishwasher hot water temperatures are frequently checked to ensure cleanliness and sanitation of dishware, failing to ensure safe refrigerator temperatures and failing to dispose of outdated food items. This practice had the potential to affect all residents that consumed food that was prepared by the kitchen.

Inspectors wroteBased on observation and staff interview, it was determined that the facility staff failed to provide residents with dignity and respect by improperly transporting residents down the hall (Resident #70, Resident #173 Resident #21 and assisting a resident to eat (Resident #65). These events were evident during 5 random observations on the facility nursing units during the survey.

Inspectors wroteBased on interview and review of facility reported incident (FRI) investigation documentation it was determined the facility staff failed to thoroughly investigate incidents of alleged verbal and physical abuse. This was evident for 5 of 6 residents (Resident #9, #225, #226, #275, #276) reviewed for abuse.

Inspectors wroteBased on record reviews, observation, and staff interview, it was determined that the facility failed to: 1) develop and implement comprehensive person-centered care that were resident specific with measurable objectives and goals (Resident #26, #66, #57, #273) and 2) develop a care plan to address the use of an anticoagulant (Resident#58). This was evident for 5 out of 55 residents reviewed during an annual recertification survey.

Inspectors wroteBased on observation, medical record review and staff interview it was determined the facility failed to have a process to ensure that residents with a limited range of motion received the appropriate treatment and services to prevent further decline in range of motion. This was evident for 3 of 4 residents (Resident #21, #26, #66) reviewed for limited range of motion during the survey.

Inspectors wroteBased on observations, staff interviews, and record review, it was determined that the facility failed to obtain accurate weights and verify weights as needed. This was found to be evident for 4 residents out of 4 residents (Resident #3, #57, #176, #178) reviewed for nutrition and hydration during an annual recertification survey.

Inspectors wroteBased on medical record review and staff interview it was determined the facility staff failed to have a process to ensure that medication regimen reviews occur monthly for all residents and pharmacist recommendations were timely acted upon and documented in the resident's medical record. This was evident for 6 of 6 residents (Resident #24, #28, #31, #41, #67, #180) reviewed for unnecessary medications. Additionally, the facility failed to develop policies and procedures related to time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident.

Inspectors wroteBased on the review of the medical record review, observations, and interviews, it was determined the facility staff failed to: 1) maintain medical records in the most accurate form as the facility failed to completely identify the positions of staff in the electronic health record. All resident records are affected by this lack of staff identification; 2) maintain medical records on each resident in accordance with accepted professional standards and practices that are complete and accurately documented. This was evident for 3 out of 8 residents (Residents #25 and #32 and #180) reviewed for medical records during the survey

Inspectors wroteBased on observation, record review, and staff interview, it was determined that the facility failed to maintain strict infection control processes evidenced by: 1) staff failing to keep a urinary catheter bag off the floor. This was evident for 1 of 4 residents (#57) reviewed for a foley catheter and 2) failed to provide education and convey updates to staff on COVID-19. This deficient practice has the potential to affect all residents, staff, and visitors in the facility.

Inspectors wroteBased on record review and staff interview, it was determined that the facility staff failed to document that resident and/or their Responsible Parties (RPs) were provided education on Influenza and Pneumococcal vaccines before requesting consent. This was evident for 5 (Resident #25, #26, #32, #53, and #67) of 5 residents reviewed for Immunizations during the survey.

Inspectors wroteBased on the staff interview, review of facility policies, and facility's tracking record, it was determined the facility failed to provide COVID-19 testing for the unvaccinated staff. This was evident for 3 of 50 staff (Licensed Practical Nurse (LPN) #39, Registered Nurse (RN) #40, and Geriatric Nursing Assistant (GNA) #41) reviewed for COVID-19 testing during the survey.

Inspectors wroteBased on medical record review and staff interview, it was determined the facility failed to: 1) document education provided regarding the benefits, risks, and potential side effects of receiving the COVID-19 vaccine to residents and staff, and 2)maintain a consent form in the residents' medical record. This was evident for 1 of 5 residents (Resident #67) and 8 facility staff members reviewed for COVID-19 vaccinations during the survey.

Inspectors wroteBased on complaints, reviews of an active and closed medical records, and complainant and staff interviews, it was determined that the facility staff failed to immediately notify a resident's physician when: 1) a resident had a hypoglycemic event (Resident #65), and 2) when a resident was identified with a significant weight loss (Resident #176). This was evident for 2 of 9 complaints reviewed during an annual recertification survey.

Inspectors wroteBased on record review, staff and resident interviews it was determined that the facility staff failed to ensure that residents were free from abuse and neglect. This was evident for 3 of 6 residents (Resident #9, #225, #272) reviewed for facility reported incidents related to abuse and neglect allegations.

Inspectors wroteBased on reviews of a facility reported incidents, the facility abuse policy, and staff interview, it was determined that the facility failed to notify local law enforcement of an allegation of misappropriation of resident property. This was evident for 1 of 8 residents (Resident #181) reviewed for abuse during an annual recertification survey.

Inspectors wroteBased on medical record review and staff interview it was determined that the facility failed to document the transfer or discharge of a resident was necessary for the resident's welfare and the resident's needs could not be met in the facility. This was evident for 1 of 4 residents (Resident #3) reviewed for discharges and transfers during an annual recertification survey.

Inspectors wroteBased on medical record review and staff interview it was determined the facility failed to notify the resident/resident representative in writing of a transfer/discharge of a resident along with the reason for the transfer. This was evident for 2 of 4 residents (Resident #28, #3) reviewed for facility-initiated transfers.

Inspectors wroteBased on medical record review and staff interview, it was determined that the facility failed to orient, prepare, and document a resident's preparation for a transfer to the hospital. This was identified for 1 of 4 residents (Resident #28) reviewed for hospitalization during the annual survey.

Inspectors wroteBased on medical record review and staff interview it was determined the facility failed to notify the resident/resident representative in writing of the bed hold policy upon transfer of a resident to an acute care facility. This was evident for 3 of 5 residents (Resident #28, #3, #41) reviewed for transfers out of the facility.

Inspectors wroteBased on medical record review, and staff interview it was determined that the facility failed to have an effective system in place to ensure care plans are thoroughly evaluated and revised by the interdisciplinary team after each assessment. This was evident for 3 of 3 residents (Resident #26, #32, #66) reviewed for care plan revision.

Inspectors wroteBased on medical record review and interview it was determined that the facility failed to ensure staff followed physician orders as evidenced by: 1) failure to ensure ordered consults were addressed. This was evident for 1 of 4 (Resident #57) residents reviewed during the survey; 2) failure to change, label, date and initial oxygen tubing and humidifier bottle. This was evident for 1 of 8 residents (Resident #32) reviewed during the survey. Although this noncompliance resulted in no actual harm to the residents, it has a potential for more than minimal harm if the practice is not corrected.

Inspectors wroteBased on complaint, reviews of a clinical record, and complainant and staff interviews, it was determined that the facility failed to identify a resident who was at risk for pressure wounds and implement and take steps to create a baseline care plan with nursing interventions to prevent a pressure wound. This was evident for 1 of 5 residents (Resident #65) reviewed for pressure ulcers during an annual recertification survey.

Inspectors wroteBased on medical record review, staff interview, and observation it was determined that the facility failed to ensure: 1) admitted with a Foley catheter was assessed for removal of the catheter timely (Resident #65); 2) follow a care plan which included positioning foley bag (Resident #57); 3) follow the physician's order for a follow-up appointment with a urologist 1 week after admission (Resident #57), and 4) follow a physician's order for catheter care (Resident #57). The failure of the facility to assess the foley catheter usage placed the resident at risk for infection. This was evident for 2 of 4 residents reviewed for foley catheters during the survey. A Foley catheter is a thin, sterile tube inserted into the bladder to drain urine. Always place the drainage bag below the level of the bladder and off the floor to prevent getting infections. [...]

Inspectors wroteBased on observation and staff interview, it was determined the facility failed to properly store medications as evidenced by failing to ensure that medication and treatment carts were locked when unattended. This was evident for 1 of 2 treatment carts observed on the 2nd floor unit.

Inspectors wroteBased on observation, resident and staff interviews, and medical record review, it was determined that the facility failed to provide dental services within a reasonable time frame following a physician's dental consult request. This was evident for 1 of 2 residents (Resident #26) reviewed for dental.

Inspectors wroteBased on observation, and staff interview it was determined that the facility staff failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. This was found to be true for 1 of 2 units (3rd floor) observed during the environmental tour of the facility. This deficient practice has the potential to affect all residents, staff, and visitors on the unit.

Inspectors wroteBased on review of facility documents and interviews of facility staff, and resident council, it was determined that the facility failed to act promptly upon the resident council's grievances and concerns. All residents have the potential to be affected by the concerns raised by the resident council.

Inspectors wroteBased on observations, review of daily staffing records, and staff interview it was determined the facility failed to post the total number and actual hours worked by categories of Registered nurses, Licensed practical nurses, and Certified nursing aides per shift and failed to have the staff data requirements available in an accurate, clear and readable format. This was identified that the facility did not have staffing information readily available in a readable format for residents and visitors for 14 out of 14 days of the survey.

Inspectors wroteBased on reviews of a medical record and staff interviews, it was determined that the facility failed to notify all current residents that if it is discovered that the resident has a positive test for COVID-19, the resident may have to be transferred to another facility. This was evident for 1 of 2 residents (Resident #3) reviewed regarding infection control during an annual recertification survey.

Inspectors wroteBased on observation, it was determined that the facility staff failed to provide a resident with an adaptive type call bell that would allow the resident to summon staff while wearing bilateral hand mittens. This was evident for 1 (Resident #29) of 28 residents reviewed during an annual recertification survey.

Inspectors wroteBased on medical record review, resident and staff interviews, it was determined the facility staff failed to notify Resident (#6), the Guardian or Responsible Party (RP) verbally or in writing of a planned room change. This was evident for 1 of 28 residents selected for review during the survey process.

Inspectors wroteBased on record review and interview, it was determined the facility staff failed to maintain a current advanced healthcare directive within the medical record indicating Residents (#2) choices regarding life sustaining treatment. This was evident for 1 of 28 residents selected for review during the survey process.

Inspectors wroteBased on review of administrative documents, complaint and staff interview, it was determined that a facility staff member failed to report an allegation of 1) missing money in a timely manner to the facility administrator, and 2) report an allegation of abuse to the State survey agency. This was evident for 2 (Resident #2 #71) of 28 residents reviewed during an annual recertification survey.

Inspectors wroteBased on record review, staff and resident interviews it was determined the facility staff failed to initiate an investigation after an allegation of abuse was made by a resident (Resident #6). This was evident for 1 of 28 residents reviewed during the survey process.

Inspectors wroteBased on medical record review and interview, it was determined that the facility failed to notify the resident or their responsible party in writing with a copy to the state ombudsman of resident's (Resident #39, #40, #56) transfer to the hospital and the reasons for the transfer. This was evident for 3 of 28 residents sampled during the annual survey.

Inspectors wroteBased on medical record review and interview, it was determined that the facility failed to notify the resident or the resident's responsible party in writing of the facilities bed-hold policy (Resident #39, #40, #56) before or soon after transferring them to the hospital. This was evident for 3 of 28 residents reviewed during the annual survey.

Inspectors wroteBased on review of the medical record and interviews with staff, it was determined that the facility staff failed to develop a comprehensive side or bed rail use care plan for a resident (#30). This was evident for 1 of 28 residents reviewed during the annual survey.

Inspectors wroteBased on clinical record review and staff interview it was determined that the facility staff failed to 1) ensure that quarterly resident care plan meetings were held within the required timeframes, 2) follow a resident's protective device care plan by documenting that the staff is checking a resident's distal pulses, and 3) update a resident's care plan regarding the prolonged use of an antibiotic cream around a gastrostomy tube site (Residents #6, #11, #29). This was true for 3 out of 28 residents reviewed during a recertification survey.

Inspectors wroteBased on review of a medical record and staff interview, it was determined that the facility staff failed to address the continued use of an antibiotic cream for a resident. This was evident for 1 (Resident #11) of 28 residents reviewed during an annual recertification survey.

Inspectors wroteBased on medical record review, resident observation and staff interview, it was determined that the facility staff failed to ensure that a resident's environment was free from potential accidents (Resident #30). This was evident for 1 of 28 residents selected for review in the annual survey.

Inspectors wroteBased on medical record review and interview, it was determined the facility staff failed to obtain consent from the resident or their responsible party before initiating side or bed rails on the resident's bed (Residents #30 and #56). This was evident for 2 of 28 residents reviewed in the annual survey.