Autumn Lake Healthcare at Bridgepark

Inspectors wroteBased on complaint, reviews of a medical record, and staff interview, it was determined that the nursing staff failed to: 1) follow a physicians orders for withholding a cardiovascular medication when the pulse rate was less than 100 and document the resident's pulse rate when administering the cardiovascular medication, and 2) correctly document the route the cardiovascular medication should be administered. This was evident for 1 of 2 residents (Resident #1) reviewed during the complaint survey.

Inspectors wroteBased on observation during the initial tour of the facility on 11/13/2025 at 5:35 AM, it was determined that the facility nursing staff failed to maintain the medication carts locked and secure. This was evident for 3 of 4 nursing units observed during a complaint survey.

Inspectors wroteBased on record review and interviews, it was determined that the facility failed to ensure nursing staff were competent with their skills set. This was evident for 3 (Staff #14, Staff #29, and Staff # 30) of 5 nursing staff evaluated for competency and has the potential to affect all residents.

Inspectors wroteBased on record review and interviews, it was determined that the facility failed to provide 12 hours of in-service training to nurse aides yearly. This finding was evident for 2 Geriatric Nursing Assistants (GNA #15 and GNA #16) of 2 nurse aide employee files reviewed during the recertification survey.

Inspectors wroteBased on observations and interviews, it was determined that facility staff failed to 1.) maintain the facility's floors and resident shower room in a clean and sanitary condition and 2.) failed to ensure privacy for male and female residents who share a joint bathroom. This deficient practice was evident for multiple areas observed for cleanliness and resident privacy during the annual survey.

Inspectors wroteBased on record review and interviews, it was determined the facility failed to ensure comprehensive care plans were developed and implemented. This was evident for 1 resident (Resident#104) out of 17 facility reported investigations, and 2 (Resident #58 and Resident #92) out of 6 residents reviewed for care plans.

Inspectors wroteBased on record reviews and interviews, it was determined that facility staff failed to 1.) ensure that a tube feeding container was labeled 2.) follow professional standards when caring for a resident who had a change in condition. This deficient practice was evident for one resident (Resident #53) out of 9 residents reviewed for tube feedings during the annual survey and one (#87) resident reviewed for nursing standards during the annual survey.

Inspectors wroteBased on record reviews, observation, and interviews, it was determined that the facility failed to have documented evidence to support that the facility provided an ongoing program to support residents in their choice of activities. This was evident for 1 (Resident #73) of 3 resident reviewed for activities during the Medicare/Medicaid recertification survey.

Inspectors wroteBased on observations, record reviews, and interviews, it was determined that facility staff failed to ensure a resident wore an arm splint as ordered by the physician. This deficient practice was evident for one (# 11) resident reviewed for position and mobility and 1 (Resident #58) of 2 residents reviewed for range of motion during the annual survey.

Inspectors wroteBased on record reviews and interviews, it was determined that facility staff failed to ensure a treatment order was in place for a resident with a suprapubic catheter, and 2.) failed to change a resident for extended periods following episodes of incontinence. This deficient practice was evident for two (#4, #47) of two residents reviewed for bowel and bladder incontinence during the annual survey.

Inspectors wroteBased on surveyor observations, review of the medical record, and interview with facility staff, it was determined the facility staff failed to provide residents with respiratory care consistent with professional standards by failing to 1) properly date label oxygen tubing when changed and 2) Change the water in the humidifier. This was evident for 1 resident (Resident #10) out of 9 residents on oxygen reviewed during the Medicare/Medicaid recertification survey.

Inspectors wroteBased on record review and interviews, it was determined that the facility failed to comply with State Regulations when the facility failed to provide nursing staff with a minimum of 2 hours of training on cognitive impairment annually. This was evident for 5 (Staff #13, Staff #14, Staff #15, Staff #16, and Staff #17,) of 5 nursing staff evaluated for cognitive impairment training and has the potential to affect all residents.

Inspectors wroteBased on record review and interviews it was determined the facility staff failed to maintain medical records on each resident that are complete and accurately documented. This was evident for 1) 1 (#94) of 3 residents reviewed for an injury of unknown origin, 2) 1 (Resident #86) out of 2 resident's reviewed for death in the facility, 3) 2 (Resident #33 and #60) of 5 residents reviewed for pressure ulcers, 4) 1 (Resident #30) of 3 residents reviewed for activities, and 5) 1 resident (Resident#104) out of 17 facility reported investigations reviewed during an annual survey.

Inspectors wroteBased on record reviews, and interviews, it was determined that facility staff failed to 1.) provide adequate supervision of a resident identified with inappropriate sexual behavior towards residents and staff resulting in actual harm to Resident #11, and 2.) ensure two-person assistance was provided while providing care to a resident in bed, as required by the resident's care plan. This deficient practice was evident for 2 of 5 residents (#11 and #98) reviewed for accidents during the annual survey.

Inspectors wroteBased on record review and staff interview, it was determined that the facility failed to provide reasonable accommodations of preferences by not honoring a resident's request for female only caregivers. This was found to be evident for Resident #105 during investigation of facility reported incident MD00186826.

Inspectors wroteBased on record reviews and interviews it was determined that facility staff failed to notify a resident's representative of a change in the resident's medical condition and failed to inform the resident's representative of the resident's transfer to the hospital. This deficient practice was evident for one (#89) resident reviewed for notification of changes during the annual survey. The term resident representative means the following: An individual chosen by the resident to act on behalf of the resident in order to support the resident in decision-making; access medical, social or other personal information of the resident; manage financial matters; or receive notifications.

Inspectors wroteBased on record reviews and staff interviews, it was determined that the facility failed to ensure that a resident remained free of abuse. This deficient practice was evident for one (#11) of five residents reviewed for abuse during the annual survey.

Inspectors wroteBased on review of facility reported incident investigation, review of record and interviews, it was determined the facility failed to 1) report an allegation of abuse in a timely manner to the state agency, immediately, but not later than two hours after the allegation was made, and 2) report an injury of an unknown source to the state agency as required. This was evident for 1 resident (Resident #106) of 17 residents reviewed for timely reporting an alleged violation, and 1 resident (#94) of 3 residents reviewed for an injury of unknown origin during an annual survey.

Inspectors wroteBased on review of a facility reported incident it was determined the facility failed to 1) ensure the thorough investigation of an allegation of abuse, and 2) provide residents with psychological evaluations and physician assessments following a substantiated incident of resident to resident sexual abuse. This was evident for 1 (Resident #106) out of 17 residents reviewed for allegations of abuse, and 1 (MD#00193881) of 17 Facility Reported Incidents (FRI) reviewed during the annual survey.

Inspectors wroteBased on medical record review and interviews it was determined the facility staff failed to ensure that the required minimum information was provided to the receiving provider upon transfer from the facility. This was evident for 1 (#94) of 3 residents reviewed for an injury of unknown origin.

Inspectors wroteBased on record review and interviews, it was determined that the facility failed to revise care plans for residents. This was evident for 1 (MD#00207171) out of 17 facility reported investigations, 2 (Resident #100, #27) out of 5 residents reviewed for care plans reviewed during an annual survey.

Inspectors wroteBased on record review and interviews, it was determined that the facility staff failed to provide a resident (Resident #92) with oral care. This was evident for 1 (MD#00206301) of 46 intakes reviewed during the recertification survey.

Inspectors wroteBased on record review and interviews, it was determined that the facility failed to provide adequate physical therapy services to a resident (Resident #92). This was evident for 1 (MD#00206301) of 46 intakes reviewed during the recertification survey.

Inspectors wroteBased on medical record review and interview it was determined the facility staff failed to provide needed care to Residents (#9, #78, #75, #83 and #66) to provide the highest practical well-being. The facility staff failed to administer medications to Resident #9 as ordered by the physician, failed to float heels for Resident #78, failed to obtain a neurology consultation for Resident #75, failed to obtain a neurology consultation for Resident #83 and failed to obtain a Heptalogy and GI consultation for Resident #66. This was evident for 5 of 52 residents selected for review during the annual survey process.

Inspectors wroteBased on medical record review, observation and interview, it was determined the facility staff failed to provide Resident #9 with the prescribed diet as ordered by the physician; failed to obtain weights on Resident # 75 for 5 months, failed to withhold straw for Resident #83 and facility staff failed to thoroughly monitor and add interventions timely when the facility staff documented a significant weight loss for a resident (Resident #77). This was evident for 4 of 7 residents selected for review for nutrition and 4 of 52 residents selected for review during the annual survey.

Inspectors wroteBased on medical record review, it was determined the facility staff failed to 1. address Consultant Pharmacy Drug Regimen Review in a timely manner for Residents (#9 and #22) and 2. document a monthly Consultant Pharmacy Drug Regimen Review in the resident's chart. This was evident for 2 of 5 residents reviewed for unnecessary medication and 2 of 52 residents selected for review during the annual survey sample

Inspectors wroteBased on observation and staff interview, it had been determined that the facility had not implemented infection control practices to prevent the spread of COVID 19 as evidenced by 1. facility staff failing to wear a face mask while working in the facility and providing during patient care (This was observed 3 times during an annual recertification survey) and 2. the facility staff failed to store/ handle dirty linens in a manner that would limit the spread of infections as much as possible and in accordance with the accepted national standard to decrease the spread of any infections (This was observed 1 time during an annual recertification survey).

Inspectors wroteBased on medical record review and interview, it was determined the facility staff failed to 1. ensure Resident #83's responsible party (RP) was provided the opportunity to consent to the flu vaccine for Resident #83 and 2. failed to ensure Resident #285 had a representative when signing documents. This was evident for 2 of 2 residents selected for reviewed for dignity and 2 of 52 residents selected for review during the annual survey.

Inspectors wroteBased on resident interview, staff interview and observation it was determined that the facility staff failed to ensure signage was posted to alert residents and visitors of the location of the survey results. This was evident for 4 out of 4 units.

Inspectors wroteBased on medical record review it was determined the facility staff failed to notify 1. the physician of results of an ammonia level (Resident #75) and 2. the physician and resident's family member of X-ray results (Resident #85). This was evident for 2 of 52 residents selected for review during the annual survey process.

Inspectors wroteBased on a review of the beneficiary notices and staff interview it was determined that the facility staff could not provide sufficient evidence that the residents are provided the proper notice at the time of discharge regarding Medicare coverage (Resident #4, #139 and #140). This was evident for 3 out of the 3 reviewed for the beneficiary notice task.

Inspectors wroteBased on observation it was determined that the facility staff failed to ensure the confidentiality of resident's #39 information. This was evident for 1 out of 52 residents that were part of the Annual survey process.

Inspectors wroteBased on medical record review and staff interviewed it was determined that the facility failed to ensure the resident, and/or their responsible party, received written notification of a transfer to the hospital, including appeal rights and ombudsman contact information (Residents #21, #22 and #77). This was found to be evident for 3 out of 6 residents reviewed for hospitalization during an annual survey.

Inspectors wroteBased on medical record review and staff interview it was determined that the facility staff failed to provide residents and/or their representative (RP) with the proper paper documentation of the facility's bed hold policy (Resident #21, #22 and #77). This was found evident for 3 of 6 residents reviewed for hospitalizations during an annual survey.

Inspectors wroteBased on record review, resident interview, and staff interview it was determined that the facility staff failed to ensure the accuracy of the facility assessments (Resident #60). This was evident for 1 out of the 52 residents reviewed as part of the survey process.

Inspectors wrote3. The facility failed to have quarterly care plan meetings with resident's responsible party. Review of Resident #21's medical record on [DATE] revealed the Resident was admitted to the facility on [DATE] from the hospital with a diagnosis to include vascular dementia. Vascular dementia is a decline in thinking skills caused by conditions that block or reduce blood flow to various regions of the brain, depriving them of oxygen and. nutrients. During an interview with Resident #21's responsible party (RP) on [DATE] at 8:45 AM, the RP stated the facility used to have care plan meetings every 3 months but they have not had one for the Resident in a long time. Review of the Resident's record on [DATE] confirmed no evidence of care plan meetings with the Resident's RP since [DATE]. The facility failed to hold a quarterly care plan meeting in April, July and [DATE]. [...]

Inspectors wroteBased on observation and record review, it was determined that the facility failed to administer medications within 1-hour time frame in accordance with professional standards for Resident #79. This was evident for 1 of 52 residents reviewed during the annual survey.

Inspectors wroteBased on complaint, reviews of medical record review and staff interview, it was determined that the facility failed to implement an ongoing resident centered activities program for 1 (Resident #37) of 52 residents reviewed for activities during an annual recertification survey.

Inspectors wroteBased on medical record review and interview, the facility staff failed to provide treatment/services to prevent/heal pressures ulcers and arterial wounds (Resident #10 and #21). This is evident for 2 of 52 residents reviewed during an annual survey. A pressure ulcer also known as pressure sore or decubitus ulcer is any lesion caused by unrelieved pressure that results in damage to the underlying tissue. [...]

Inspectors wroteBased on complaint, reviews of a medical record, and staff interview, it was determined that facility staff failed to obtain podiatry consultation for Resident #37 as ordered by the physician. This was evident for 1 of 52 residents selected for review during an annual survey.

Inspectors wroteBased on record review it was determined the facility staff failed to ensure Resident #83 received restorative nursing program (RNP) as ordered by the physical therapist and speech language pathologist in conjunction with the physician. This was evident for 1 of 5 residents selected for review of range of motion and 1 of 52 residents selected for review during the annual survey.

Inspectors wroteBased on medical record review and observations, it was determined the facility staff failed to provide fall mats next to the bed of Residents #75, 78 and #81. This was evident for 3 of 52 residents selected for review during the annual survey process.

Inspectors wroteBased on medical record review and interview, it was determined the facility staff failed to ensure Residents #9 and #57 were provided pain medication when requested. This was evident for 2 of 2 residents reviewed for pain and 2 of 52 residents selected for review during the annual survey process.

Inspectors wroteBased on medical record review and interview, it was determined that the facility staff failed to complete the Dialysis record communication sheet and obtain post dialysis weights and vital signs for Resident #47. This is evident for 1 of 1 resident reviewed for dialysis during the annual survey.

Inspectors wroteBased on clinical record review and staff interview it was determined that the facility staff failed to ensure medications were administered within ordered parameters. This was evident for 2 (#5 and #9) out of 7 residents reviewed for medications. This was evident for 2 of 5 residents selected for review of unnecessary medications and 2 of 52 residents selected for review during the annual survey process.

Inspectors wroteBased on record review and observation of medication administration, it was determined the facility staff failed to maintain an error rate below 5%. Observation of medication administration resulted in an error rate of 10.26%. This was evident for 2 of 4 (#33 and #13) residents observed and 4 of 39 opportunities for error.

Inspectors wroteBased on observation, it was determined that the facility staff failed to properly store medications in a locked compartment that were only accessible to authorized staff. This was observed on two different nursing units during an annual recertification survey.

Inspectors wroteBased on medical record review it was determined the facility staff failed to obtain laboratory specimens as ordered by the physician for Residents #66, #75, #83 and #85. This was evident for 4 of 52 residents selected for review during the annual survey process.

Inspectors wroteBased on complaint, reviews of a medical record, and staff interview, the facility failed to provide dental services for a resident (Resident #22). This was evident for 1 out of 52 residents selected for review during the annual survey process.

Inspectors wroteBased on medical record review and interview, it was determined the facility staff failed to maintain the medical record for Residents #81 and #184 in the most accurate and complete form. This was evident for 2 of 52 residents selected for review during an annual survey.

Inspectors wroteBased on observation, staff interview it was determined that the facility failed to maintain kitchen equipment in safe operating condition. This deficient practice has the potential to affect all residents.

Inspectors wroteBased on review of facility records and an interview with staff, it was determined the facility failed to provide revise and document an accurate up-to-date facility-wide assessment annually. This was identified during an annual recertification survey. This has the potential to affect all residents within the facility.

Inspectors wroteBased on observation and staff interview it was determined that the facility staff failed to post a staffing assignment that was complete. This was evident for 1 out of the 4 nursing units.

Inspectors wroteBased on medical record review and interview with staff it was determined that the facility staff failed to 1) provide a written notice for emergency transfers to the resident and/or the resident representative, and 2) ensure the local ombudsman was notified of a facility initiated resident discharge or transfer. This was found to be evident for 6 out of 46 (Residents #36, #39, #18, #64, #26, #70) residents reviewed for a facility-initiated transfer during an annual re-certification survey.

Inspectors wroteBased on medical record review, observation, and staff interview, it was determined that the facility staff failed to provide Residents #18, #36 and Resident #39 with services to maintain/attain the highest level of mobility. The facility staff failed to apply splints as ordered by the physician. This was evident for 3 of 46 residents selected for review during the annual re-certification survey.

Inspectors wroteBased on observation during the initial tour of the main kitchen it was determined the facility staff failed to 1. discard expired food, date and label food stored in the walk-in refrigerator, 2. properly label and store open containers in dry storage and throughout the kitchen, and 3. maintain a clean environment.

Inspectors wroteBased on observation and staff interview it was determined the facility staff failed to keep the air intake unit in the main kitchen in a clean and safe operating condition. This was evident during the initial tour of the kitchen.

Inspectors wroteBased on medical record review and staff interview, it was determined that the facility failed to follow a resident's wishes to obtain a laboratory test. This was evident for 1 (Resident #82) of 4 residents reviewed for choices during an annual recertification survey.

Inspectors wroteBased on resident complaint, reviews of administrative records including a resident's personal funds records, individual resident account statements, transaction reports, transaction receipts, and staff interview, it was determined that the facility staff failed to maintain a system that ensures a full and complete accounting of a resident's personal monies entrusted to this facility. This was evident for 1 (Resident #55) of 1 resident reviewed for personal property during an annual recertification survey.

Inspectors wroteBased on review of facility administrative records and staff interview, it was determined that the facility staff failed to immediately report an allegation of abuse to the facility administrator. This was evident for 1 (Resident #195) of 4 residents reviewed for abuse during an annual recertification survey.

Inspectors wroteBased on observation, reviews of a medical record, and staff interview, it was determined that the facility staff failed to implement a care plan for a resident who smokes. This was evident for 1 (Resident #89) of 2 residents reviewed for smoking during an annual re-certification survey.

Inspectors wroteBased on observation during a medication pass, it was determined the nurse failed to follow standards of practice regarding medication preparation and poured an excess of dispensed medication back into the medication container. This was observed one time during a medication pass observation.

Inspectors wroteBased on resident interview, reviews of a medical record, and staff interview, it was determined that the facility staff failed to obtain an eye consultation. This was evident for 1 (Resident #89) of 1 resident reviewed for communication difficulty and/or sensory problems during an annual recertification survey.

Inspectors wroteBased on medical record review and staff interviews, it was determined that the facility staff failed to ensure that a resident's medication regimen was free from unnecessary medication by failing to ensure that a psychotropic medication had an adequate indication for use. This was evident for 1 (Resident #89) of 5 residents reviewed for unnecessary medications during an annual recertification survey.

Inspectors wroteBased on staff interview and clinical record review it was determined that the facility staff failed to 1) ensure the residents' behaviors were monitored and recorded routinely, and 2) to conduct behavior monitoring for a resident receiving an psychotropic medication. This was evident for 2 (Resident #87 and #43) out of the 5 residents selected for a review for unnecessary medications during an annual recertification survey.

Inspectors wroteBased on observation and staff interview it was determined that the facility staff failed to ensure the treatment and medication carts were locked and secured. This was true for 2 out of 4 nursing units.

Inspectors wroteBased on observation, reviews of a medical record, and staff interview, it was determined that the facility staff failed to obtain dental services for a resident. This was evident for 1 (Resident #55) of 1 resident reviewed for dental services during an annual recertification survey.

Inspectors wroteBased on resident complaint, medical record review and staff interview, it was determined that the facility therapy staff failed to evaluate and take steps to reassess a resident's wheelchair. This was evident for 1 (Resident #6) of 1 resident reviewed for rehabilitation and restorative nursing services during an annual recertification survey.

Inspectors wroteBased on reviews of a medical record and staff interview, it was determined that the facility staff failed to maintain an accurate medical record by not including documentation from the facility hospice service provider in the medical record. This was evident for 1 (Resident #82) of 2 residents reviewed for hospice services during an annual recertification survey.

Inspectors wroteBased on administrative record review and staff interview, the facility staff failed to track and monitor a resident with an infection upon admission. This was evident for 1 (Resident #193) of 2 residents reviewed for infections during an annual recertification survey.

Inspectors wroteBased on observation, reviews of a medical record, and staff interview, it was determined that the facility staff failed to identify a resident as a smoker, assess the resident to be a safe smoker, implement a care plan for smoking, and update the facility list of smokers. This was evident for 1 (Resident #89) of 2 residents reviewed for smoking during an annual recertification survey.