Autumn Lake Healthcare at Perring Parkway

Inspectors wroteBased on medical record review, observation and interview, it was determined that the facility staff failed to identify and consistently evaluate the contributing factors to a resident fall and ensure appropriate interventions were implemented to prevent future occurrences. This was evident for 1 of 2 (#6) residents reviewed for falls and resulted in harm to Resident #6.

Inspectors wroteBased on observation and interview, it was determined that facility staff failed to maintain the facility in a homelike environment. This was evident for 3 of 3 observations of unit 1 and unit 2.

Inspectors wroteBased on observation, record review, and interview, it was determined that facility staff failed to ensure that a resident was treated with dignity. This was evident for 1 (#5) of 3 residents observed during the complaint survey

Inspectors wroteBased on record review and interview, it was determined that the facility failed to have a process in place to ensure residents/resident representatives had the right to a grievance process. This was evident for 1 (#1) of 6 residents reviewed for complaints.

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 within the required timeframe. This was evident for 4 of 4 abuse allegations reported to staff for Resident #3.

Inspectors wroteBased on record review and interview, it was determined that the facility failed to have a process in place to ensure that all allegations of abuse were investigated and appropriate interventions put into place to ensure resident were free of abuse. This was evident for 3 of 4 allegations of abuse reported regarding Resident #3.

Inspectors wroteBased on record review and interview, it was determined that the facility failed to have a process in place to ensure that residents were appropriately discharged from the facility. This was evident for 1 (#3) of 1 discharge reviewed.

Inspectors wroteBased on medical record review, observation and interviews, it was determined that the facility failed to accurately code a residents' active diagnosis and skin conditions on the minimum data set (MDS). This was determined during the review of complaints related to general care in 2 of 4 residents (#6 and #7).

Inspectors wroteBased on observation and interview, it was determined that the facility failed to provide the residents with a quality of care and dignity by timely responding to call bells and providing residents with the appropriate adult incontinence briefs. This was evident during random observations and 1 of 1 resident (#6) observed for the use of incontinence briefs.

Inspectors wroteBased on medical record review and interview with facility staff, it was determined that the physicians failed to have their signed notes in the medical record timely after seeing the resident and ensure their notes were individualized and reflected the status of the resident. This was evident 1 of 2 (Resident #7) residents reviewed during a complaint survey.

Inspectors wroteBased on observation and interview it was determined the facility failed to ensure a homelike environment. This was evident for 2 of 2 facility floors of the building during the facility's recertification survey.

Inspectors wroteBased on observation and interview it was determined the facility failed to ensure dignity was maintained for Resident #24. This was evident for 1 out of 1 Resident (#24) reviewed for dignity during the facility's recertification survey.

Inspectors wroteBased on record review and staff interviews, it was determined that the facility failed to ensure a resident's right to formulate an Advanced Directive and maintain accurate documentation within their medical record. This was evident for 4 (Resident #2, #5, #64, and #57) out of 6 residents reviewed for Advanced Directives during the survey.

Inspectors wroteBased on observation, record review, and interview with staff, it was determined that the facility failed to ensure the baseline care plan was thoroughly completed and included the resident -specific initial goals based on admission orders needed to properly care for the resident immediately upon their admission. This was evident for 1(Resident #99) out of 4 residents reviewed for care planning during the annual survey.

Inspectors wroteBased on record review and interview with staff, it was determined that the facility failed to ensure residents and/or resident representatives were offered the opportunity to participate in their care planning process by holding timely quarterly care plan meetings. This was evident for 2 (Resident #31 and Resident #57) out of 4 residents reviewed for care planning during the annual survey.

Inspectors wroteBased on observation, record review, and interviews, it was determined that the facility failed to ensure a resident was offered the opportunity to participate in facility sponsored group activities. This was evident for 1 (Resident #54) out of 2 residents reviewed for activities during the annual survey.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure a resident's dry skin condition was identified and failed to ensure they received intervention to address the condition. This was evident for 1 out of 1 Resident (#24) reviewed for skin conditions during the facility's recertification survey.

Inspectors wroteBased on record review and interview with the resident and the staff, it was determined that the facility failed to ensure a resident receives proper treatment and scheduled follow-up appointments to maintain vision. This was evident for 1 resident (Resident #57) reviewed for vision services during the annual survey.

Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to ensure consistent incontinence care was provided. This was evident for 1 out of 1 Resident (#4) reviewed for bowel and bladder incontinence during the facility's recertification survey.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to: 1.) ensure respiratory tubing and the humidification saline bottle was dated and timed in accordance with professional standards and ensure a respiratory nebulizer machine, face mask, tubing and saline bottle was stored off of the floor's surface. This was evident for 2 out of 2 Residents (#98, #10) reviewed for respiratory during the facility's recertification survey.

Inspectors wroteBased on observation and interviews with staff, it was determined that the facility failed to ensure an appropriate storage method was implemented for medications awaiting final disposition consistent with standards of practice. This was evident for an observation in 1 medication room (Station 2) out of 2 medication rooms observed during the annual survey.

Inspectors wroteBased on record review and interviews with the resident and staff, it was determined that the facility failed to assist the resident in obtaining routine dental care. This was evident for 1 resident (Resident #57) reviewed during the annual survey.

Inspectors wroteBased on observations, interviews and resident medical record review it was determined the facility failed to provide a diet that meets the residents special dietary needs and taking consideration of the resident's preferences. This was evident for 1(Resident #8) out of 6 residents reviewed and observed during the annual survey.

Inspectors wroteBased on observations, review of facility documentation and interviews and it was determined the facility failed to follow the menu for residents' meals. This was evident for 2 (Resident #8 and #58) out of 6 residents reviewed during the survey.

Inspectors wroteBased on interview and record review it was determined the facility failed to 1.) ensure a resident admitted with severe cognitive impairment had two physician certifications completed and in the medical record, and failed to ensure the MOLST form reflected surrogacy as the basis of the orders and failed to ensure physician documentation of advanced directives and the molst form being reviewed was present in the medical record, and 2.) failed to ensure accuracy of a documented indication for use of a medication in a medical order. This was evident for: 1.) 1 out of 5 Residents (#10) reviewed for advanced directives, and 2.) 1 out of 1 Resident (#24) reviewed for skin conditions during the facility's recertification survey.

Inspectors wroteBased on observation and interview, it was determined that the facility failed to ensure tube feeding equipment was properly dated to prevent potential infection control risks. This deficient practice was evident for 1 (Resident #9) of 1 resident reviewed for tube feeding.

Inspectors wroteBased on interviews, and medical record reviews it was determined that the facility staff failed to 1) ensure a resident received proper care to prevent the removal of a skin graft which led to the failure of the skin graft procedure and caused harm to Resident #94 by prolonging healing of the wound; 2) administer insulin before meals as ordered and failed to follow the hypoglycemia protocol as ordered which led to harm for Resident #91 when the low glucose incident required Resident #91 to be transferred to the hospital Intensive Care Unit for care; 3) provide wound care to a resident who had a surgical wound (Resident #84). This was evident for 3 of 45 residents selected for review during the survey.

Inspectors wroteBased on medical record review and staff interview it was determined the facility failed to develop, implement, and update a person-centered care plan for each resident to meet a resident's medical, nursing, and mental and psychosocial needs. This was evident for 4 residents (#32, #80, #76, #14) out of 15 residents reviewed during the survey.

Inspectors wroteBased on medical record review and staff interview it was determined the facility failed to ensure that residents were free from unnecessary drugs due to inadequate monitoring. This was evident for 5 residents (#32, #14, #70, #18, #44) out of 13 residents reviewed during the annual survey.

Inspectors wroteBased on review of the resident electronic medical record and interviews with facility staff it was determined the facility failed to provide the resident and/or responsible party a written copy of the hospital transfer summary. This was found to be evident during the facility's Medicare/Medicaid survey.

Inspectors wroteBased on clinical record review and staff interview it was determined that the facility staff failed to ensure its residents had a complete and accurate Preadmission Screening and Record Review (PASRR). This was evident for 1 out 45 of residents (Resident #47) in the survey sample.

Inspectors wroteBased on medical record review and staff interview it was determined the facility failed to provide the resident and their representative with a written summary of the baseline care plan within 48 hours of the resident's admission. This was evident for 1 resident (#32) out of 8 residents reviewed during the annual survey.

Inspectors wroteBased on medical record review and interviews it was determined the facility staff failed to update a resident's care plan who had a wound and a resident with a history of falls. This was evident in 3 (#84, #36, #70) residents out of 8 resident records reviewed for updated care plans during the survey.

Inspectors wroteBased on a review of the resident medical record and interviews with the facility staff it was determined the facility failed to properly assess a resident for bedrails. This was found to be evident for 1(Resident # 14) of 7 residents reviewed for accidents during the facility's survey.

Inspectors wroteBased on medical record review and interview it was determined that the facility failed to ensure the physician and nurse practitioners accurately assessed a resident's medications (Resident #91) and wound dressing instructions (Residents #94). This was found to be evident for 2 out of 45 residents reviewed during an the survey.

Inspectors wroteBased on interviews, medical record reviews, and observations the facility failed to provide pharmaceutical services that assured accurate dispensing and administering of medications to meets the needs of each resident. This was evident for 1 of 1 resident (Resident # 287) reviewed during the survey.

Inspectors wroteBased on medical record review and staff interview it was determined the facility pharmacist failed to identify and report irregularities in resident (#70's) drug regimen to the Physician, facility's Medical Director and/or the Director of nursing. This was evident for 1of 5 residents reviewed for unnecessary medications.

Inspectors wroteBased on observation, record review, and interviews it was determined that the facility failed to ensure the medication error rate was less than 5%. This was evident for 2 of 25 opportunities for medication errors with an error percentage of 7.14% observed during the medication administration facility task performed.

Inspectors wroteBased on medical record review and staff interviews it was determined that the facility failed to administer prescribed mediation to residents. This was found to be evident for 2 out of 45 (Resident #94, #287) reviewed during the annual survey.

Inspectors wroteBased on medical record review and staff interview it was determined the facility failed to accurately maintain resident face sheet/Emergency Data sheet with diagnoses that reflected his/her condition. This was evident for 1 resident (#32) out of 8 residents reviewed during the survey.

Inspectors wroteBased on observations and interviews of the residents and facility staff it was determined the facility failed to ensure that the resident's call system was functioning properly. This was found to be evident for 1 of multiple resident rooms observed during the facility's survey.

Inspectors wroteBased on record review and interview, it was determined the facility staff failed to notify the physican of a heart rate below the set parameter as ordered for Resident (#68), failed to notify the physician of a weight gain for Resident (#234) and failed to notify the Power of Attorney (POA)/or emergency contact of changes in condition for Resident (#68 and #233) and the facility staff failed to notify a resident's physician of a positive ultrasound result timely manner for Resident (#21). This was evident for 4 of 4 residents selected for change in condition investigation during the annual survey process and 4 of 39 residents selected for review during the annual survey process.

Inspectors wroteBased on review of the medical record and staff interview, it was determined that the facility staff failed to provide the resident and their representative with a written notice of bed hold policy, at the time of the resident transfer for hospitalization. This was evident for 3 (#38, #58, #59) of 8 residents reviewed for Hospitalization during an annual recertification survey and 3 of 39 residents selected for review during the annual survey process.

Inspectors wroteBased on staff interview and employee record review (Staff #8), it was determined that the facility failed to complete the required performance review of a geriatric nursing assistant at least once every 12 months in 1 employee record reviewed during this survey.

Inspectors wroteBased on observation and interviews of facility staff, it was determined that food service employees failed to ensure that sanitary practices were followed, equipment was maintained and safe food handling practices were followed to reduce the risk of foodborne illness. This deficient practice has the potential to affect all residents.

Inspectors wroteBased on observation and interview, it was determined the facility staff failed to provide Resident #16 with the most dignified existence. This was evident for 1 of 2 residents investigated for dignity during the survey process and 1 of 39 residents selected for review during the annual survey process.

Inspectors wroteBased on observation and interview, the facility staff failed to honor residents (# #58, #283, #183) menu choices and shower requests. This was evident for 3 of 3 residents reviewed for choices during the annual survey and 2 of 39 residents reviewed during the annual survey.

Inspectors wroteBased on resident complaint, reviews of a medical record and staff interview, it was determined that the facility staff failed to 1. take steps to protect a resident's property from becoming lost, and 2. maintain a current list of a resident's belongings. This was evident for 1 (Resident #183) of 1 resident reviewed for personal property during an annual recertification survey 1 of 39 residents selected for review during the annual survey and the facility staff failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior.

Inspectors wroteBased on medical record review and interview with staff it was determined that the facility staff failed to provide a written notice for emergency transfers to the resident and/or the resident representative and the facility failed to provide and resident and the resident's family member with written notification regarding an emergent transfer to the hospital Resident (#183). This was found to be evident for 4 out of 8 residents reviewed for a facility-initiated transfer during the investigative portion of the survey and 4 of 39 residents selected for review during the annual survey.

Inspectors wroteBased on resident complaint, reviews of a medical record and staff interview, it was determined the facility staff failed to initiate a care plan to address a resident's behaviors of wandering into other resident rooms. This was evident for 1 (Resident #40) of 4 residents reviewed for accidents during an annual recertification.

Inspectors wroteBased on medical record review, observation and staff interview, it was determined the facility staff failed to provide services to Resident #334 as stated in the care plan. This was evident for 1 of 3 residents reviewed for care plans during the annual survey process.

Inspectors wroteBased on medical record review, observation and interview, it was determined the facility staff failed to ensure the dose of a medication was as accurate as possible. This was evident for 1 of 6 residents observed for medication pass and 1 of 33 opportunities for error.

Inspectors wroteBased on clinical record review, staff interview, and observation it was determined that the facility staff failed to ensure an order for the use of a hand splint was followed (#22) and the facility staff failed to apply a heel protective device for Resident (#183). This was true for 2 out of the 6 residents reviewed for Range of Motion during the annual survey process. The evidence is as follows: 1. A review of Resident #22's clinical record revealed that the primary physician wrote an order on 4/5/18 to Don right hand orthotic 9AM, remove at 3PM. This surveyor observed on 2/1/19 at 1:59 PM the resident laying in bed with right hand below the bed sheets. I asked the unit manager to lift the sheets so that the hand could be observed. When he lifted the sheet, it was observed that the hand splint was not on the resident. The unit manager said he would put the hand splint on the resident. [...]

Inspectors wroteBased on medical record review and interviews with facility staff, it was determined that the facility staff failed to follow a written physician order to prevent loss of range of motion (Resident #51). This is evident for 1 of 4 resident's reviewed for limited range of motion.

Inspectors wroteBased on medical record review, observations, and staff interviews it was determined that facility staff failed to ensure a resident was free from accident hazards. This is evident for 2 out of 2 residents selected for reveiw of accidents during the survey and 2 (#54 and #67) out of 39 residents reviewed during the investigative stage of the survey.

Inspectors wroteBased on record review, observation and interview, it was determined the facility staff failed to provide Resident #16 with the most provisions to provide for optimal nutrition. This was evident for 1 of 12 residents selected for review of nutrition and 1 of 39 resident selected for review during the annual survey.

Inspectors wroteBased on record review, observation and interview, it was determined the facility staff failed to have emergency equipment a manual ventilation bag (Ambu) at the bedside for Resident #334 in accordance with the standard of practice. This was evident for 1 of 1 resident selected for review of respiratory care/tracheotomy during the annual survey process.

Inspectors wroteBased on medical record review and interview it was determined the facility staff failed to thoroughly assess the need for pain medication for Resident (#16). This was evident for 1 of 4 residents selected for pain assessment and 1 of 39 residents selected for review during the annual survey.

Inspectors wroteBased on medical record review and interview, it was determined the Certified Registered Nurse Practitioner failed to determine the significance and need of an ordered laboratory blood test for Resident #67. This was evident for 1 of 39 residents selected for review during the annual survey process.

Inspectors wroteBased on record review, observation and interview, it was determined the facility staff failed to maintain a medication error rate below 5%. Based on observation of medication pass on 2/1/19 the facility staff failed to administer medications to Resident (#49) resulting in an error rate of 6.06%. This was evident of 2 of 33 opportunities for error and 1 of 6 residents observed during medication pass.

Inspectors wroteBased on observation and interview, it was determined the facility staff failed to ensure medications were thoroughly labeled with residents' name. This was evident for 1of 5 medication carts observed during the annual survey process.

Inspectors wroteBased upon resident interview, staff interview and medical record review it was determined that facility staff failed to assist a resident in obtaining routine and emergency dental care for Resident # 38. This was evident for 1 of 4 residents selected for review of dental during the survey process.

Inspectors wrote2. The facility staff failed to maintain complete and accurate medical records. On 1/30/2019 at 12:16 PM a copy of Resident #54's Care Plan was obtained from the Director of Nursing (DON). A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess and evaluate the effectiveness of the resident's care. Review of the Care Plan revealed that the copy presented to surveyors by the DON was inconsistent with the Care Plan stored digitally within Point Click Care (PCC). PCC is a software program used by facilities to digitally manage resident records, medications and care plans. It is commonly used as a reference by employees when providing care to residents. [...]

Inspectors wroteBased on medical record review, observation and interview, it was determined the facility staff failed to provide the most effective infection control practices while administering medications to Resident (#52) and facility staff failed to reduce the risk of cross contamination and spread of infections by not washing hands after direct patient care for Resident # 334. This was evident for 1 of 6 residents observed for medication pass and 1 out of 33 opportunities for error (Resident #52) and 1 out of 2 residents reviewed for a facility-initiated transfer during the investigative portion of the survey.

Inspectors wroteBased on observation and interview of facility staff, it was determined that the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public. This deficient practice has the potential to affect all residents.