Autumn Lake Healthcare at Bradford Oaks

Inspectors wroteBased on observation, interviews, and record review, it was determined that the facility failed to provide respiratory care consistent with professional standards for oxygen administration. This was found evident of 6 (Resident #13, #23, #41, #133, #149, #171) out of 7 residents reviewed for respiratory care during the survey. Nasal cannula- a medical device used to provide supplemental oxygen therapy to people who have lower oxygen levels. An oxygen concentrator is a medical device that extracts oxygen from room air by filtering out or separating the nitrogen from the oxygen. The oxygen passes through a filter system and is then stored within the device for delivery based on the flow meter setting.

Inspectors wroteBased on interviews and record review, it was determined that the facility failed to provide the resident/resident representative with written notification of a new roommate. This was evident for 1(Resident#73) of 1 resident reviewed for roommate changes during the recertification survey.

Inspectors wroteBased on observation and staff interview it was determined that the facility failed to ensure the personal privacy of a Resident. This finding was found to be evident in 1 (Resident #72) out of 1 Residents reviewed for urinary catheters.

Inspectors wroteBased on observation and staff interviews it was determined that the facility failed to maintain a safe, comfortable, homelike environment for Residents. This finding was found to be evident in 9 (Resident rooms/bathrooms N34 N39, N40, N42, N46, N50, N34, N62 and S72) out of 9 Resident rooms/bathrooms reviewed, and 1 (North Unit shower room) out of 1 shower rooms reviewed for physical environment during the recertification survey.

Inspectors wroteBased on staff and Resident interviews and surveyor record reviews it was determined that the facility failed to provide notification to the Ombudsman of Residents that transferred to the hospital. This finding was found to be evident in 2 (Resident #10 and #72) out of 2 Residents reviewed for discharge process.

Inspectors wroteBased on Resident and staff interviews and surveyor record reviews it was determined that the facility failed to ensure that 1) care plan meetings were conducted and documented for Resident # 13, and 2) care plans were updated and revised following changes in Resident's condition. This finding was found to be evident for 4 (Resident #7, #11, # 72, and #23) out of 5 Residents reviewed for care planning.

Inspectors wroteBased on observations, clinical record review and interviews, it was determined that the facility failed to provide an activities program to meet the needs and interests of a resident. This was evident for 1 (Resident #14) of 1 resident reviewed for activities during the recertification survey.

Inspectors wroteBased on interviews and record review, it was determined that the facility failed to ensure a follow-up assessment was completed in accordance with professional standards of practice. This was evident for 1 (Resident #168) of 1 residents reviewed for skin/head-to-toe assessments.

Inspectors wroteBased on observation and interview, it was determined that the facility failed to administer enteral feeding consistent with professional standards of practice. This was found to be evident for 1 (#74) out of 1 Resident observed for enteral feeding during the recertification survey.

Inspectors wroteBased on record review and interviews with staff, it was determined that the primary medical provider failed to review the total program of care for 1 (Resident #7) out of 50 residents reviewed during the survey. A suprapubic catheter (SPC) is a surgically created connection between the urinary bladder and the skin in the abdomen used to drain urine through a tube from the bladder to a collection bag in individuals with obstruction of normal urinary flow. Foley catheter is a flexible tube inserted through the urethra into the bladder to drain urine. It is held in place by a small, water-filled balloon. Percutaneous Endoscopic Gastric (PEG) tube, also known as a g-tube or feeding tube, is placed in a procedure that inserts a tube from the abdomen into the stomach to deliver nutrition, fluids, and medications directly into the stomach.

Inspectors wroteBased on record review and interviews it was determined that the facility failed to have a process in place that ensured a Resident's medication irregularity reports were reviewed by the primary care physician and the actions taken based on the recommendations were being documented. This was found evident of 1 (Resident #13) of 5 Residents reviewed for medication regimen review.

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on record review and staff interviews, it was determined that the facility failed to ensure that each resident's medication regimen was free from unnecessary medications. This was evident for 1 (Resident #4) of 5 residents reviewed for unnecessary medication during the annual survey.

Inspectors wroteBased on observations and interviews with staff, it was determined that the facility failed to store medication in a locked compartment. This was found evident on 2 of 2 random observations.

Inspectors wroteNumber of residents sampled: Number of residents cited: F812, F 584 and F757F812Based on observation and staff interviews, it was determined that the facility failed to store, prepare, distribute, and serve food in a manner that prevents foodborne illness to the residents. This was evident during the annual survey and has the potential to affect most residents in the facility.

Inspectors wroteBased on observation and staff interviews it was determined that the facility staff failed to maintain infection prevention and control practices. This finding was found to be evident on 1 (North Nursing Unit) out of 3 nursing units reviewed for physical environment during the annual recertification survey.

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on observation and staff interviews, it was determined the facility failed to provide individual closet space for a resident. This was evident for Resident # 20 during the annual re-certification survey.

Inspectors wroteBased on observation and staff interview it was determined that the facility failed to have call light cords accessible for Residents and failed to ensure that the resident's call system was functioning properly. This finding was found to be evident in 2 (Resident #68 and #76) out of 28 Residents reviewed call light accessibility and 1 (Resident #7) of 1 call light reviewed for call light functionality.

Inspectors wroteBased on observation, interviews and record review, it was determined that the facility failed to ensure an effective pest control program. This was evident for 1 (Resident #168) out of 1 residents reviewed for pests during the recertification survey.

Inspectors wroteBased on record review and interview, it was determined the facility staff failed to notify the Responsible Party when a resident (Resident #2) Pressure Ulcer worsened. This was evident for 1 of 5 residents reviewed during the complaint survey.

Inspectors wroteBased on record review and interview, it was determined that the facility failed to develop a baseline care plan within 48 hours. This was evident for 1 (Resident #5) of 5 residents reviewed during the complaint survey.

Inspectors wroteBased on review of complaints, interviews and record reviews, it was determined that the facility failed to 1) hold a care plan meeting of the Interdisciplinary Team for a resident at the time of the quarterly revision of their care plans and 2) review and revise the care plan to meet resident's needs. This was evident for 2 (Resident #2 and #5) of 2 resident reviewed for care planning during complaint survey.

Inspectors wroteBased on review of a complaint, record review, and interview, it was determined that the facility failed to write a physician's order for a warm compress. This was evident for 1 (Resident #4) of 5 residents reviewed during the complaint survey.

Inspectors wroteBased on resident interviews, observations, medical record review and interviews with facility staff it was determined the facility failed to adhere to professional standards of practice when administering medications to residents. This was found to be evident for 2 (Resident # 7 and # 5) of 2 residents reviewed for medications, and 1(Resident # 13) of 3 residents reviewed during a medication administration observation conducted during a complaint survey.

Inspectors wroteBased on observations and staff interview, it was determined that the facility failed to maintain a safe and sanitary environment for residents, visitors, and staff. This was evident for the parking lot and the East hallway during the survey.

Inspectors wroteBased on record review and interview, it was determined that the facility failed to have a process in place to ensure that allegations of abuse, were reported to the state agency (SA) and within the required timeframe. This was evident for 1 (R40) of 32 residents reviewed for abuse.

Inspectors wroteBased on record review and interview, it was determined facility staff failed to ensure that an alleged perpetrator had no further access to vulnerable residents during an investigation and to conduct a thorough investigation of the allegation. This was evident for 1 (R40) of 32 residents reviewed for abuse.

Inspectors wroteBased on record review and interview it was determined that the facility failed to provide a baseline care plan to the resident's representative. This was evident for 1 (#12) of 9 residents reviewed for care to prevent pressure ulcers.

Inspectors wroteBased on observation, interview, and policy review, the facility failed to ensure that food items in the dry storage area were discarded upon the use by date printed on the carton. This failed practice had the potential to affect the six residents that received nectar thickened liquids and the nine residents that received med pass 2.0 supplement from the kitchen.

Inspectors wroteBased on record review and interview, it was determined that facility staff failed to ensure the resident's medical records were complete and accurate. This was evident for 2 (R630 and R12) of 92 residents reviewed during the survey.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to follow infection control procedures related to droplet precautions for one of one resident (R 44) reviewed for isolation precautions out of a total sample of 39. This had the potential to cause cross-contamination with other residents and staff.

Inspectors wroteBased on review of medical records and staff interviews, it was determined the facility staff failed to provide adequate supervision to ensure the safety of Resident #224 whom was cognitively and functionally impaired. This resulted in a laceration and fracture of the Resident's left arm. This was evident for 1 out of 1 resident investigated for accidents during the survey.

Inspectors wroteBased on review of medical records, observation of patient care, and interview with facility staff, it was determined that the facility failed to ensure that residents' assessments of bed mobility accurately reflected residents' ability to maneuver themselves in bed. This was evident for 3 (Residents #1, #2, #3) of 9 residents identified by the facility's lift assessments as requiring the assistance of two staff to reposition in bed.

Inspectors wroteBased on observation, the facility staff failed to ensure that Resident # 22 and Resident #160 's nails were clean. This was evident for 2 out of 6 residents investigated for Activities of Daily Living (ADL) during the survey process.

Inspectors wroteBased on observation and staff interviews the facility staff failed to ensure that Resident #64's tracheostomy was setup to the doctor's orders. This was evident for 1 out of 1 resident investigated for a tracheostomy during the survey process.

Inspectors wroteBased on meal service observations and staff interviews it was determined that the facility staff failed to follow infection control practices and guidelines to prevent the development and transmission of disease by failing to Demonstrate appropriate hand hygiene to prevent the spread of infection during lunch meal service involving resident's (R#61). This was evident during dining observation.