Autumn Lake Healthcare at Long Green

Inspectors wroteBased on record review and interview it was determined the facility staff failed to follow Nursing Standards of Practice by failing to ensure wound care treatments were completed timely, signed off at the time of completion and signed off by the person who performed the treatment. This was evident for 1 (#7) of 6 residents reviewed for Quality of Care.

Inspectors wroteBased on record review and interview it was determined that the facility staff failed to notify a resident's representative when the resident was transferred to the hospital. This was evident for 1 (Resident #7) of 6 residents reviewed for Quality of Care.

Inspectors wroteBased on record review and interview, it was determined the facility staff failed to ensure resolution of all grievances by failing to ensure that written grievance decisions included the steps taken to investigate a grievance. This was evident for 1 (#7) of 3 residents reviewed for neglect.

Inspectors wroteBased on record review and interview it was determined the facility staff failed to maintain complete and accurate medical records by failing to ensure 1) a resident's record included the actions taken to pursue a court appointed guardian, and 2) a resident's record accurately reflected their skin status upon readmission. This was evident for 2 (#5 and #2) of 6 residents reviewed for Quality of Care.

Inspectors wroteBased on observation, interviews and record review it was determined the facility staff failed to implement standard infection control practices during wound care. This was evident for 1 (#2) of 6 residents reviewed for Quality of Care.

Inspectors wroteBased on lack of documentation and interviews it was determined that the facility staff failed to complete a yearly performance review of Geriatric Nursing Assistants. This deficient practice was discovered during the recertification survey.

Inspectors wroteBased on observations, record review, and interviews with facility staff, it was determined that the facility failed to maintain food service equipment in a manner that ensures sanitary food service operations to prevent possible foodborne illness. This was evident during the initial, and follow-up tours of the kitchen.

Inspectors wroteBased on observation, record review, and staff interviews, it was determined that the facility failed to maintain essential equipment in proper operating conditions. This was evident for 10 of the 10 pieces of equipment reviewed during the annual survey.

Inspectors wroteBased on the lack of documentation and interviews it was determined that the facility staff failed to ensure Geriatric Nursing Assistants received the required 12 hours of yearly training. This deficient practice was discovered during the recertification survey.

Inspectors wroteBased on resident council records and interviews it was determined that the facility failed to have resident council meetings regularly as evidenced by the inability to provide resident council meeting minutes during January, February, March, and April 2025. The deficient practice was evident in 4 or 12 months of 2025. This deficient practice was discovered during the recertification survey.

Inspectors wroteBased upon observation and interview, it was determined that the facility failed to maintain a clean and homelike environment. This was evident for 3 Resident's (Resident #8, Resident #48 and Resident #109) of 3 resident rooms and the first-floor Nourishment Room reviewed during the annual survey. On 01/22/2026 at 1:45 PM, Resident #8 was interviewed and complained of feeling cold. The door to the bathroom was open, and a cold breeze was felt by the surveyor coming from the bathroom. The window was observed to be broken with some clear tape on the broken part of the window, but the tape did not adhere to the broken piece of glass in the windowpane, allowing cold air to enter. On 01/22/2026 at 2:03 PM, the Administrator and Staff #28, the Regional Director of Nursing, were shown the broken windowpane in Resident #8's bathroom. They were asked how this window had been broken. [...]

Inspectors wroteBased on review of the staffing sheets and interview it was determined that the facility staff failed to record the actual hours worked by categories of licensed and unlicensed nursing staff each shift. This deficient practice was discovered during the recertification survey.

Inspectors wroteBased on observations and medical record review it was determined that the facility failed to ensure appropriate infection control practices during the maintenance of oxygen concentrators. This was evident for 2 out of 2 residents reviewed with oxygen concentrators during the recertification survey.

Inspectors wroteBased on observation and interview with facility staff, it was determined that the facility failed to maintain clean and operational ventilation systems, thereby impairing proper airflow throughout the premises. This was evident in 2 of 2 janitors' closets, 2 of 2 utility closets, 2 of 2 residents toilet and shower rooms, and the mechanical dishwasher ventilation systems reviewed during the annual survey. Local Exhaust Ventilation ([NAME]) systems are designed and engineered to capture and remove contaminants such as excessive heat, steam, condensation, vapor, smoke, odor, and fumes. This is achieved through the calibration of the total pressure, which is calculated as the sum of the static pressure exiting and entering the system, minus the velocity pressure entering the system. [...]

Inspectors wroteBased on medical record review and staff interviews it was determined that the facility failed to developed and implement a person centered care plan. This was evident for 2 Resident's, Resident #12 and Resident #103 reviewed during the annual recertification survey.

Inspectors wroteBased on a review of the electronic health record and interview it was determined that the facility staff failed to obtain an order to monitor a resident's blood glucose levels and obtain parameters when the physician should be contacted which is the standard for nursing practice. This deficient practice was evidenced in 1 (#103) of 4 medical records reviewed during the recertification survey.

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on review of residents' medical records and interview with facility staff, it was determined that the facility failed to ensure that a physician's order for daily pedal pulses and weekly abdominal girth measurements to be recorded and reviewed by the provider. This is evident in 1 of 1 residents (resident #25) reviewed in the annual certification.

Inspectors wroteBased on employee record review and interviews it was determined that the facility staff failed to ensure a Certified Nursing Assistant (CNA) received their Geriatric Nursing Assistant (GNA) Certification within 4 months of their hire date. This deficient practice was evidenced in 1(#32) of three CNA employee records reviewed during the recertification survey.

Inspectors wroteBased on observations and staff interviews it was determined that the facility failed to properly store medication. This was evident in 1 of 3 medication carts reviewed during the annual recertification.

Inspectors wroteBased on medical record review and interviews with staff, it was determined that the facility staff failed to obtain a diagnostic test and get the results as ordered for Resident (#106) in a timely manner. This was evident for 1 of 21 residents selected for review during the annual survey process.

Inspectors wroteBased on observations and interviews, it was determined that the facility failed to ensure that the residents received meals that were palatable, attractive, appetizing, adequately portioned, and served at preferred temperatures. This was evident for 1 (Resident #48) of 1 Resident interview and 2 of 2 dining observations conducted during the recertification survey.

Inspectors wroteBased on observation and interviews with facility staff, it was determined that the facility failed to ensure the appropriate location and maintenance of the exterior dumpster to prevent the harborage and infestation of pests and insects.

Inspectors wroteBased on observation and interviews with facility staff, it was determined that the facility failed to ensure a call bell system was accessible to residents. This was evident for 3 (Resident #1, #44 and #109) of 3 residents' toilet facilities call bell systems reviewed during the annual survey.

Inspectors wroteBased on observation, record review, and interviews with staff and residents, it was determined that the facility failed to maintain a rodent and insect free environment for the residents. This was evident in 2 of 2 resident rooms and the conference room reviewed during the annual survey.

Inspectors wroteBased on observation, interviews with residents and staff, and a review of facility processes, the facility failed to ensure an adequate supply of clean, well-maintained linen was available to meet the needs of residents. This deficient practice affected 4 (Resident #5, #10, #15, #16) of the 16 residents reviewed during the complaint survey.

Inspectors wroteBased on observation, interviews with residents and staff, and a review of facility processes, the facility failed to ensure an adequate supply of clean, well-maintained linen was available to meet the needs of residents. This deficient practice affected 4 (Resident #5, #10, #15, #16) of the 16 residents reviewed during the complaint survey.

Inspectors wroteBased on medical record review and interview with staff it was determined the facility failed to notify a resident/resident representative in writing of a room change, including the reason for the change. This was evident for 1 (Resident #1) of 6 residents reviewed for a facility reported incident during the complaint survey.

Inspectors wroteBased on observation and interview with facility staff and residents it was determined that the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. This was observed on all nursing units.

Inspectors wroteBased on record review, observation, and interview with facility staff and residents, it was determined that facility staff failed to follow professional standards of nursing practice when administering medications to residents. This was evident for 2 (Resident #9 and #88) of 7 residents selected for a medication administration audit record (MAAR) review during the survey.

Inspectors wroteBased on observations and interviews it was determined that the facility failed to ensure: 1) appropriate temperature monitoring was maintained for the medication refrigerator, 2) expired medications were properly discarded, and 3) appropriate labeling and storage of medications. This was evident in 2 out of 2 medication storage rooms observed in the facility and 4 of 7 medication carts observed in the facility.

Inspectors wroteBased on observation and interview with facility staff, it was determined that the facility failed to ensure residents' rights to dignity and privacy as evidenced by 1) not ensuring that a resident's foley drainage bag was covered, this was evident for 1 (Resident #86) of 2 residents reviewed for dignity and 2) the facility staff not putting the residents' clothing away in drawers or hanging them in the armoires. This deficient practice was evidenced in 30 of 33 residents screened during the Medicare/Medicaid survey.

Inspectors wroteBased on observations and interviews it was determined that the facility staff failed to ensure residents had their call bells readily accessible when assistance was required. This deficient practice was evidenced in 3 (#11, #13, & #14) of 33 residents reviewed for accommodations of needs during the survey.

Inspectors wroteBased on administrative record review and interviews with facility staff it was determined the facility failed to ensure that a resident was free from misappropriation of their funds while residing in the facility. This was found to be evident for 1 (Resident # 111) of 3 resident's reviewed for personal property during the survey.

Inspectors wroteBased on record review and interview with facility staff, it was determined that the facility failed to timely report allegations of abuse within the required two hour timeframe to the Survey Agency, the Office of Health Care Quality (OHCQ). This was evident for 2 (MD00204913 and MD00202949) of 5 facility related incident reports reviewed during the survey.

Inspectors wroteBased on record review and interview with facility staff, it was determined that the facility failed to complete a thorough investigation of an allegation of abuse. This was evident for 1 of 10 residents (Resident #36) reviewed for abuse during the survey.

Inspectors wroteBased on medical record review and interviews with facility staff it was determined the facility failed to complete a baseline care plan on a resident admitted with a stage four pressure ulcer. This was evident for 1 (Resident # 98) reviewed for pressure ulcers during the facility's annual survey.

Inspectors wroteBased on review of the medical record, observation and interviews with facility staff, it was determined that the facility failed to ensure comprehensive care plans were developed and implemented. This is evident for 2 (Resident #98 and #88) of 37 residents reviewed during the survey.

Inspectors wroteBased on medical record review and interview it was determined that the facility staff failed to reassess a resident's blood pressure (BP) when it was outside of the resident's usual parameters. This deficient practice was evident in 1 (#68) of 1 resident reviewed for follow up after abnormal vitals during the survey.

Inspectors wroteBased on medical record review and staff interview it was determined the facility failed to ensure that treatment that was ordered for a resident with urinary incontinence was implemented. This was evident for 1 (#93) of 3 residents reviewed for bladder incontinence.

Inspectors wroteBased on surveyor observation, interview with facility staff, and review of the medical record, it was determined the facility staff failed to provide necessary respiratory care services for residents by failing to date label oxygen administration equipment and failing to administer oxygen as prescribed. This was evident for 1 (Resident #60) of 37 residents reviewed during the survey.

Inspectors wroteBased on a review of the medical record and interview with facility staff, it was determined that the facility failed to respond to the pharmacy recommendations after a monthly clinical review was done and failed to ensure the attending physician reviewed the pharmacy reviews. This was evident for 2 (Resident # 93 and #88) of 5 residents reviewed for unnecessary medications during the survey.

Inspectors wroteBased on a review of the medical record and interviews with facility staff it was determined that the facility failed to respond to the pharmacy recommendations after a monthly clinical review was done. This was found to be evident for 1(Resident # 93) of 5 residents reviewed for unnecessary medications during the facility's annual survey.

Inspectors wroteBased on administrative record reviews, observations, and interviews the failed to (1) ensure sanitary practices were followed in accordance with professional standards for food service safety, (2) maintain a clean working environment, #3) to remove expired canned food from the kitchen, (4) maintain safe temperatures in a unit refrigerator, and (5) to remove outdated food from unit refrigerators. These deficient practices related to the unit refrigerators were identified to be present on 2 out of 4 clinical units and the facility kitchen.

Inspectors wroteBased on record review and interview with facility staff, it was determined that the facility failed to ensure that resident's medical records were accurately documented in accordance with accepted professional standards. This was evident for 1 (Resident #68) out of 8 resident's records reviewed during the survey.

Inspectors wroteBased on observations and interviews with facility staff it was determined the facility failed to ensure that infection control practices were maintained to prevent the spread of germs and transmission of microorganisms. This was evident for 1 (Resident #39) of 37 residents reviewed and found to be present when observations were made during the survey.

Inspectors wroteBased on observations and interviews with facility staff it was determined the facility failed to ensure that the resident's environment was maintained in a safe and homelike manner. This was found to be evident for multiple residents that resided in rooms (#121,122,123,124,126, 219 and 226) of 7 resident rooms observed during the facility's survey.

Inspectors wroteBased on observations and interviews of facility staff it was determined the facility failed to ensure an effective pest control program as flies and fruit flies were observed throughout the building. This was found to be evident during the facility's survey.

Inspectors wroteBased on reviews of facility reported incidents, record review and interview it was determined the facility failed to report allegations of abuse within 2 hours of the allegation to the regulatory agency, the Office of Health Care Quality (OHCQ). This was evident for 4 (#15, #36, #13, #18) of 54 residents reviewed during a complaint survey.

Inspectors wroteBased on complaint, medical record review and interview, it was determined that the facility staff failed to create and implement care plans related to resident's specific needs. This was evident for 5 (#4, #19, #30, #32, #7) of 54 residents reviewed during a complaint survey.

Inspectors wroteBased on medical record review, interview, and complaint review, it was determined the the facility staff failed to administer medications and provide treatments as ordered by the physician and failed to provide care in accordance with professional standards of practice and resident's choices. for residents. This was evident for 6 (#2, #25, #26, #19, #1, #5) of 54 residents reviewed during a complaint survey.

Inspectors wroteBased on medical record review and interview, the facility staff failed to include a resident's representative (RP) in the A) admission process and B) care planning (Resident #41). This was evident for 1 of 54 residents reviewed during a complaint survey.

Inspectors wroteBased on review of complaint, medical records, and interview, it was determined that the facility failed to review the admission agreement, which includes a notice of the resident's rights, with a resident at the time of admission and failed to ensure the admission agreement was signed and documented. This was evident for 1 (#23) of 54 residents reviewed during a complaint survey.

Inspectors wroteBased on review of a complaint, interview, and medical record review, it was determined the facility failed to notify the physician when medications were not available to be administered to residents. This was evident for 1 (#5) of 54 residents reviewed during a complaint survey.

Inspectors wroteBased on medical record review, facility documentation and interviews, it was determined the facility staff failed to protect a resident from verbal abuse from facility staff (Resident #18). This was evident for 1 of 54 residents reviewed for abuse during a complaint survey.

Inspectors wroteBased on review of facility reported incidents, facility investigations, and staff interview, it was determined the facility failed to thoroughly investigate incidents of alleged abuse and neglect. This was evident for 3 (#15, #36, #14) of 54 residents reviewed during a complaint survey.

Inspectors wroteBased on medical record review and interview, it was determined the facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded (Resident #43). This was evident for 1 of 54 residents reviewed during a complaint survey.

Inspectors wroteBased on record review and interview with facility staff, it was determined that the facility failed to ensure that a recapitulation of the resident's stay was completed following a resident's discharge from the facility. This was evident for 1 (#30) of 54 residents reviewed during a complaint survey.

Inspectors wroteBased on medical record review and interview, the facility staff failed to provide activities of daily living (ADL) to a dependent resident (Resident #21). This was evident for 1 of 54 residents reviewed during a complaint survey.

Inspectors wroteBased on medical record review and interview, the facility staff failed to provide treatment/services to prevent/heal pressures ulcers. This was evident for 3 (#16, #33, #43) of 54 residents reviewed during a complaint survey.

Inspectors wroteBased on complaint, record review, and interview, it was determined the physician/nurse practitioner failed to review the resident's total care as evidenced by documenting the resident was still being followed by physical and occupational therapy even though the resident was discharged from therapy. This was evident for 1 (#1) of 54 residents reviewed during a complaint survey.

Inspectors wroteBased on review of a complaint, interview, and medical record review, it was determined the facility failed to timely provide medication to meet the needs of the residents. This was evident for 2 (#5, #44) of 54 residents reviewed during a complaint survey.

Inspectors wroteBased on interview and medical record review, it was determined the facility failed to adequately monitor the resident's heart rate and blood pressure while taking an antihypertensive medication and failed to monitor the heart rate and blood pressure when a resident was not administered the medication while waiting for delivery of the medication from the pharmacy. This was evident for 1 (#5) of 54 residents reviewed during a complaint survey.

Inspectors wroteBased on review of complaint, medical record review, and interview, it was determined that the facility failed to ensure that residents who require dental services on a routine or emergent basis receive necessary or recommended dental services in a timely manner. This was evident for 1 (#32) of 54 residents reviewed during a complaint survey.

Inspectors wroteBased on observation and interview with facility staff it was determined that the facility failed to stored food in a sanitary manner. This was observed on 1 of 4 nursing units.

Inspectors wroteBased on medical record review and interview, it was determined the facility staff failed to ensure a resident went to scheduled out of the facility physician visits in a timely manner. This was evident for 2 (#17, #28) of 54 residents reviewed during a complaint survey.

Inspectors wroteBased on medical record review and interview, it was determined the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards. This was evident for 4 (#19, #42, #17, #43) of 54 residents reviewed during a complaint survey.

Inspectors wroteBased on observations, review of daily staffing records, and staff interview it was determined that the facility failed to 1) update the staffing boards with all of the staff names working that shift, at the beginning of the shift and 2) post the total number and actual hours worked by categories of Registered Nurses (RN), Licensed Practical Nurses (LPN), and Certified Geriatric Nurse Aides (GNA) per shift. This was evident for 4 of 4 nursing units, the lobby, and review of nursing schedules.

Inspectors wroteBased on multiple observations it was determined the facility failed to maintain an environment that was clean, comfortable, and homelike for residents. This deficient practice had the potential to affect all residents.

Inspectors wroteBased on review of resident council meeting minutes and interview with residents and facility staff, it was determined that the facility failed to give adequate responses to grievances presented by the resident council. This was found evident in the review of the monthly resident council meeting minutes and facility responses for the months of November 2018-July 2019.

Inspectors wroteBased on reviews of administrative records and staff interview, it was determined that the nursing administrative staff failed to: 1) conduct a yearly performance review of geriatric nursing assistants, and 2) ensure that all geriatric nursing assistant (GNA) staff completed a minimum of 12 hours of education per year. This was evident for 6 of 7 GNA records reviewed during the investigative stage of the survey.

Inspectors wroteBased on the interviews from residents and the results from a test tray it was determined that the facility failed to maintain adequate temperatures over 135 degrees for hot cooked meals. This was evident during the testing of a breakfast and lunch tray, tested for palatability and temperature.

Inspectors wroteBased on observation it was determined that the facility failed to provide a resident with dignity and respect by improperly transporting a resident down the hall. This was evident during a random observation.

Inspectors wroteBased on medical record review, it was determined that the facility staff failed to take proper steps to void an older Medical Orders for Life-Sustaining Treatment form located in a resident's active medical record. This was evident for 1 of 28 residents (Resident #63) reviewed during an annual recertification survey.

Inspectors wroteBased on medical record review and interview with the facility staff it was determined that the facility failed to ensure Quarterly Minimum Data Set (MDS) assessments accurately reflected the resident's status as evidenced by failure to accurately code a resident's medication use. This was evident for 1 out of 28 (Resident #77) records reviewed during the investigation stage of the survey.

Inspectors wroteBased on observations, medical record review, staff and family interview it was determined the facility failed to develop and implement a care plan that addressed: 1) the need for supervision with meals for a cognitively and functionally impaired resident (Resident #59) who experienced significant weight loss; and 2) Resident #65's desire to have scheduled times to get out of bed. This was evident for 1 of 3 resident's review for care plan development during this annual recertification survey.

Inspectors wroteBased on medical record review, staff and family interviews it was determined the facility failed to 1) demonstrate evidence of collaboration between the facility and hospice services in the development of an individualized care plan that addressed comfort and care needs (Resident #71) and 2) revise a resident's safe smoking care plan (Resident #63. This was evident for 2 of 28 residents (Resident #71 and #63) reviewed during an annual recertification survey.

Inspectors wroteBased on observation, medical record review and interview of facility staff, it was determined that the facility failed to promote the activities of daily living (ADL's) of an individual by encouraging him/her to eat as identified in their care plan (Resident #25). This was identified during a meal observation.

Inspectors wroteBased on medical record review and staff interview, it was determined the facility staff failed to: 1) provide evidence that a functionally impaired resident (Resident #53) received assistance with activities of daily living or documented a rationale for not providing the care; 2) consistently document the provision of showers and baths for Resident #71 and #55 reasons for refusal of care and interventions to address refusals. This was evident for 3 of 3 residents reviewed for Activities of Daily Living during this annual recertification survey.

Inspectors wroteBased on medical record review and staff interview, it was determined the facility failed to evidence the implementation of an ongoing program of activities based on the abilities, interests and treatment needs of Resident #65 and Resident #4. This was evident for 2 of 3 residents reviewed for activity needs during this annual recertification survey.

Inspectors wroteBased on medical record review, it was determined that the facility staff failed to address a pharmacy recommendation and obtain a diagnosis and a reason to continuously administer a nasal steroid spray daily for 2 months when the resident no longer had symptoms. This was evident for 1 of 6 residents (Resident #97) reviewed for unnecessary medications during an annual recertification survey.

Inspectors wroteBased on medical record review and staff interview it was determined the facility staff failed to discontinue Ativan (anti-anxiety medication) that was ordered to be given as needed or document a rationale for continuing the order beyond 14 days. This was evident for 1 of 3 residents (Resident #71) reviewed for unnecessary medication use during this annual recertification survey.

Inspectors wroteBased on observation and staff interview, it was determined the facility staff failed to properly store medications. This was observed three times during an annual recertification survey.

Inspectors wroteBased on observation during meal service it was determined that a facility staff failed to serve the meal under sanitary conditions. This was evident during a breakfast service for dependent residents.