Autumn Lake Healthcare at Cherry Lane

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive, person-centered care plan that specified the level of assistance a resident required for transfers/mobility for 1 (Resident #2) of 10 sampled residents.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure staff revised a resident's comprehensive person-centered care plan to reflect the resident's current transfer needs for 1 (Resident #6) of 10 sampled residents.

Inspectors wroteBased on observation and interviews it was determined that the facility failed to maintain a resident's right to privacy. This was evident for 1 (Resident #137) out of 1 residents observed for privacy.

Inspectors wroteBased on two complaints of alleged witnessed allegations of abuse and interview with facility staff, it was determined that the facility failed to report to the State agency no later than 2 hours after the allegation was made and results of all investigations were reported within 5 working days. This was evident for 2 of 2 allegations of abuse identified during a complaint survey for Residents # 158 and #72.

Inspectors wroteBased on clinical record review and staff interview it was determined that the facility staff failed to code a resident's discharge status accurately on the Minimum Data Set (MDS) assessment. This was evident for 1 (#152) of 3 residents selected for closed record review during the annual survey.

Inspectors wroteBased on medical record review and facility staff interviews, it was determined that the facility failed to initiate care plans. This was evident for 3 residents (#118, #156 and #161) out of 3 residents reviewed for care plan implementation during a recertification survey process.

Inspectors wroteBased on record review and interview, it was determined that the facility failed to hold care plan meetings of the interdisciplinary team for residents at the time of the quarterly revision of their care plan. This was evident for 1 (Resident #115) of 7 residents reviewed for care planning.

Inspectors wroteBased on review of employee personnel files and staff interview, it was determined that the facility failed to complete annual performance reviews for the Geriatric Nursing Assistants (GNA). This was identified for 1 (#18) of 5 GNA staff members reviewed during the annual survey.

Inspectors wroteBased on record review and staff interview, it was determined that the facility failed to provide adequate monitoring of residents on psychotropic medications for side effects. This finding was evident for 1 (Resident #2) of 5 residents reviewed for unnecessary medications during the recertification survey.

Inspectors wroteBased on observation and staff interviews, it was determined that the facility failed to properly label and store drugs. This was found to be evident in 1 of 1 medication cart observed during the survey recertification process.

Inspectors wroteBased on observations, interviews and record reviews it was determined that the facility failed to store food in a manner that maintains professional standards of food service safety. This was evident in the Kitchen and in 2 (2A/B and 1A/B) of 4 Nutrition Rooms in the facility. This practice had the potential to affect all residents that eat food prepared by the facility's kitchen and that store food in nutrition rooms.

Inspectors wroteBased on observation, interviews and record review, it was determined that the facility failed to ensure appropriate infection control practices. This was evident for 1 (Resident #16) of 59 residents reviewed for infection control during the recertification survey.

Inspectors wroteBased on record reviews and staff interviews it was determined that the facility failed to screen and offer vaccinations to residents. This was evident for 2 (Residents #20 and #138) out of 5 residents screened for immunizations.

Inspectors wroteBased on medical record reviews, interviews and observations it was determined that the facility failed to ensure medical records were complete, readily assessable and organized. This was evident for 2 (Resident #163 and #137) of 2 residents reviewed for medical record storage.

Inspectors wroteBased on surveyor observation and staff interview it was determined the facility staff failed to keep the building clean, neat, attractive and in good repair. This was evident on both floors of the facility.

Inspectors wroteBased on interviews and record review it was determined the facility failed to perform a thorough investigation of an allegation of abuse. This was evident for 4 (Resident #253, #1, #175, and #71) out of 6 residents reviewed for abuse.

Inspectors wroteBased on a review of a complaint intake, medical record review, and staff interview it was determined that the facility failed to document the reason leading up to a transfer of a resident to the hospital in the medical record including a reason for the transfer. This was evident for 1 (Resident #160) of 6 residents reviewed for hospitalization.

Inspectors wroteBased on medical record review and staff interview it was determined the facility staff 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 4 (Residents #105, 119, 106, and 160) of 6 residents reviewed for Notice requirements before transfer/discharge.

Inspectors wroteBased on record review and interviews, it was determined that the facility failed to failed to develop and implement comprehensive, Resident-centered care plans for residents residing in the facility. This was evident for 5 (Resident #71, #252, #177, #93, and #399) of 33 resident care plans reviewed during the survey.

Inspectors wroteBased on medical record review, interviews, and observations it was determined the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards. This was evident for 8 (Resident #69, #148, #43, #253, #31, #50, #71, #72) of 83 residents reviewed during the survey.

Inspectors wroteBased on observation and staff interview, it was determined that the facility staff failed to maintain the resident call system in working order. This was evident for 2 (Unit 2C and Unit 1B) of 4 nursing units observed during the annual survey.

Inspectors wroteBased on interviews and documentation review, it was determined the facility failed to ensure a training program was set up and in place for their staff to be educated on Abuse, neglect, and exploitation, and resident abuse prevention. This was evident for 5 (Staff #14, #35, #36, #37, #38) out of 5 staff training records and 1 (Staff #30) of 1 nurse aide reviewed for nurse aide abuse training.

Inspectors wroteBased on observation and staff interview, it was determined that the facility staff failed to treat a resident in a dignified manner by leaving two urinals that contained urine hanging on the bedrail. This was evident for 1 (Resident #17) of 83 residents reviewed during the annual survey.

Inspectors wroteBased on observation and interview, it was determined the facility failed to accommodate the needs of a resident by failing to ensure the call bell was in reach when needed. This was evident for 1 (#39) of 83 residents reviewed during the survey.

Inspectors wroteBased on interviews and medical record review it was determined that the facility failed to have a process in place to ensure residents receive written notice of room changes. This was evident for 3 (Residents #250, #144, and #251) out of 3 residents who had expressed their concern regarding room changes during the recertification survey.

Inspectors wroteBased on medical record review, staff interview, and review of administrative records, it was determined that the facility failed to provide written notification to residents when the facility determined that a resident no longer qualified for Medicare part A skilled services. This is identified for 2 (Residents #126, and #134) of 2 residents reviewed that remained in the facility after termination of Medicare part A services.

Inspectors wroteBased on Interviews, review of the medical record, and observation, it was determined the facility failed to properly recognize and address a resident grievance. This was evident for 1 (Resident #253) out of 1 resident who was reviewed for grievances.

Inspectors wroteBased on observation record review and staff interview, it was determined that the facility failed to adequately assess and complete the Minimum Data Set (MDS) for a resident with impaired speech. This was evident for 1 (Resident #13) of 7 residents assessed for communication and sensory and 1 (Resident #50) of 6 residents reviewed for abuse during an annual survey.

Inspectors wroteBased on medical record review, resident, and staff interview, it was determined that the facility staff failed to revise and update a comprehensive care plan for a resident with a suprapubic catheter. This was evident for 1 (#18) of 83 residents reviewed during the survey.

Inspectors wroteBased on a complaint, medical record review, and interview it was determined that the facility failed to ensure 1) staff followed physician orders as evidenced by failure to monitor a resident's blood sugars, 2) failed to ensure right orders for treatment were put in and documented on, 3) failed to document and rotate the site of subcutaneous injection, 4) failed to manage a resident with dehydration, and 5) failed to respond to a resident's concern with swallowing difficulties. This was evident for 5 Residents (#91, #76, #148, #163, and #253) of 83 residents reviewed during the survey.

Inspectors wroteBased on record review, interview, and observation it was determined that the facility failed to properly identify, document, and monitor a resident's pressure ulcer. This was evident for 1 (Resident #71) of 6 residents reviewed for positioning and mobility.

Inspectors wroteBased on medical record review and staff interview, it was determined that the facility failed to have a system to monitor and respond to changes in residents' weights and notify the physician when residents' weight loss was identified. This was evident for 3 (Resident #158, #144, and #251) of 6 residents reviewed for nutrition during this survey.

Inspectors wroteBased on medical records review and interview with staff, it was determined the facility failed to: 1) provide a BiPAP Machine mask to a resident requiring it, 2) properly label and date an oxygen tubing when changed and follow the physician's order for the administration of oxygen, and 3) properly document the administration of oxygen. This was evidence 3 (Resident #168, #93, and #50) of 5 residents reviewed for Respiratory care.

Inspectors wroteBased on interview, observation, and medical record review, it was determined the facility failed to administer pain medication in a timely manner and according to physicians ' orders. This was evident in 1 (Resident #46) out of 2 residents who were reviewed for pain during the recertification survey.

Inspectors wroteBased on observation, interview, and record review, it was determined the facility failed to ensure that residents did not receive medications without adequate indications for their use. This finding was evident for 2 of 6 residents reviewed for unnecessary meds. (#72 and #50). 1. Albuterol is an inhaled, quick acting medication used to relieve shortness of breath caused by bronchospasm and is often ordered on a short term or as needed basis. Bronchospasm is anb abnormal contraction of the smooth muscles of the lungs, resulting in an acute narrowing and obstruction of the respiratory airway. A cough with generalized wheezing usually indicates this condition. Bronchospasm is a chief characteristic of asthma and bronchitis. Resident #72 was admitted to the facility in August 2018. [...]

Inspectors wrotex Based on interview and review of the facility records, it was determined that the facility failed to monitor and track antibiotic usage and resistance data. This was evident by 1) the duration of antibiotic use was not completed due to changing to a different salt form*, 2) a resident's antibiotic was prescribed without indication, and 3) the facility antibiotic stewardship program failed to document essential elements for antibiotic use. This was found to be true on 2 (Resident #69 and #399) out of 5 residents reviewed for antibiotic use and antibiotic stewardship program review during the annual survey.

Inspectors wroteBased on observation of Room # 250 and during an interview with Resident # 31, the facility failed to the patch the wall in the back of bed C in room [ROOM NUMBER]. This was observed for 1 out of 37 rooms.

Inspectors wroteBased on medical record review and staff interviews it was determined the facility staff failed to conduct a comprehensive assessment when a significant weight gain occurred in Resident #104's condition. This was evident for 1 of 3 residents reviewed for change in condition during the survey process.

Inspectors wroteBased on medical record review and staff interviews is was determined that the facility failed to revise and update the care plan that addressed a resident's after change in condition. This was evident 1 out of 37 resident's involving Resident #104 during the survey process.

Inspectors wroteBased on observation and staff interviews the facility staff failed to label a vaccine vial with the date when opened. This was evident for 1 out of 2 medication rooms observed during the survey process.