Autumn Lake Healthcare Post-Acute Care Center

Inspectors wroteBased on record reviews and staff interviews, it was determined that the facility failed to ensure physician orders and provider recommendations were implemented timely following changes in condition. This was evident for 1 (Resident #6) of 10 residents reviewed for quality of care during the complaint survey.

Inspectors wroteBased on reviews of a closed medical record and all pertinent administrative records, and staff interview, it was determined that the facility failed to have a system in place to ensure clinical records were complete and accurately documented. This was found to be evident for 1 (Residents #1) of 3 residents reviewed during a complaint survey.

Inspectors wroteBased on record reviews and staff interviews, it was determined that the facility failed to adhere to professional standards of quality of care based on established clinical practices, physician orders, or facility policies regarding enteral feeding and medication administration. This was evident for 4 residents (Residents #9, #210, #208 and #117) out of 4 residents reviewed for professional standards of quality care during the survey.

Inspectors wroteBased on observations, interviews with staff and residents' families, and review of Complaints, it was determined that the facility failed to 1.) ensure a safe, functional, sanitary, and comfortable environment for residents, staff, and the public; 2.) provide enough clean linen to all residents; and 3.) ensure repairs were made to a resident door and the hallways hand railings. This was evident for 5 (333137, 333135, 333139, 333141 and 333113) out of 5 complaint intakes; 2 (residents #11 and #140) out of 2 residents; and the hallway railing on the third-floor dementia unit observed for sanitary conditions during the survey.

Inspectors wroteBased on observations and interviews with facility staff, it was determined that the facility failed to ensure that residents' rights to a dignified existence during meals and incontinence care for residents. This was evident for 4 residents (#4, #188, #31 and #58) of 7 residents observed for dignity during the survey. 1. On 11/20/2025 at 11:00 AM the surveyor reviewed the Dietary Meal Serving form provided by the facility. The third-floor lunch meal delivery time was listed as 11:55 AM and 12:05PM for the residents listed as needing assistance with the meal. On 11/20/2025 at 12:08 PM the surveyor interviewed the GNA #24 regarding how the residents were monitored and/or fed in the dining room during meals. GNA #24 stated that she had been employed by the facility for the past three years. [...]

Inspectors wroteBased on observations and interviews the facility failed to ensure the residents were provided with a homelike environment related to their rooms. This was determined to be true for three resident rooms, # 312, # 309, and #316 on one unit during surveyor observation tours at the facility.

Inspectors wroteBased on record reviews and staff interviews, it was determined that the facility failed to review and revise the care plan after each Minimum Data Set (MDS) assessment known as required . This was evident for 1 (Resident #32) out of 2 residents selected for Dialysis review during the survey.

Inspectors wroteBased on observations and interviews, it was determined the facility failed to 1.) maintain up-to-date activity calendars in the residents' rooms; 2.) ensure the residents received activities that addressed the specific preferences and/or stimulation requested by family members of a dependent resident; and 3.) demonstrate that consistent activity services were provided and documented. This was evident for 3 (Residents #6, #101, and #1) residents out of 17 residents reviewed for Activities during the survey.

Inspectors wroteBased on observations and interviews of facility staff it was determined the facility failed to ensure that a resident received appropriate supervision during care. This was found to be evident for 1 (Resident # 80) of 2 residents reviewed for accidents during the survey conducted at the facility.

Inspectors wroteBased on observations, interviews, and record reviews, it was determined that the facility failed to ensure safe enteral feeding practices by failing to: 1) ensure a resident's tube feeding was properly labeled with the rate of infusion; and 2.) ensure the time the feeding was hung and an inactive feeding setup was disconnected from the resident's PEG site to prevent potential complications of enteral feeding and to maintain dignity. This was evident for 3 (residents #9, #66 and #87) of 7 residents observed on tube feeding on during the survey.

Inspectors wroteBased on observations, record reviews and staff interviews, it was determined that the facility failed to ensure that respiratory care, including tracheostomy care and tracheal suctioning, was provided consistent with professional standards of practice. This was evident for 4 (Residents #6, #101, #26 and #66) out of 12 residents observed with Tracheostomy tubes during the survey.

Inspectors wroteBased on staff interviews, interviews with the family, and record review, it was determined that the facility failed to ensure that each resident's drug regimen was free from unnecessary drugs, such as those in excessive dosage or given for an excessive duration. This was evident for 1 (Resident #208) out of 1 resident reviewed for unnecessary drugs.

Inspectors wroteBased on staff interviews, interviews with the family, and record review, it was determined that the facility failed to ensure that residents were free of any significant medication errors. This was evident for 1 (Resident #208) out of 1 resident reviewed for medication errors.

Inspectors wroteBased on observation and interview, the facility failed to ensure the kitchen was maintained in a sanitary manner to prevent the potential for food contamination. This deficient practice had the potential to affect any resident who consumes food prepared in the kitchen. Findings Include:During an observation on 11/18/25 at 9:00 AM, the following were noted in the kitchen food-service area:1. A large pile of dark black substance was observed on the floor under a shelf inside the walk-in freezer.2. The lid holder tray contained dried food residue.3. Chipping paint was observed on a post within the kitchen.4. Standing water was present on the floor near the dishwasher.5. Ten (10) ice cubes were observed spaced out across the kitchen floor. During follow-up observations on 11/19/25 at 10:00 AM and 11/20/25 at 11:00 AM, the above unsanitary conditions remained unaddressed. [...]

Inspectors wroteBased on staff interviews, interviews with the family, and record review, it was determined that the facility failed to ensure that medical records and forms were complete and accurately documented. This was evident for 3 (Resident #208, Residents #213, and Resident #214) out of 3 resident reviewed for medical records.

Inspectors wroteBased on observations and interviews with facility staff it was determined the facility failed to adhere to infection control practices and guidelines to prevent the spread of germs and cross contamination of microorganisms in the facility. This was found to be evident for 5 occurrences 1.) Resident #31 during the initial tour and screening of residents; 2.) Resident #73 during a lunch dining observation; 3.) An observation made during a tour of the laundry area; 4.) An observation of a Clean Linen bin placed within a resident-use bathroom; and 5.) The urinary catheter bag of resident #26 observed on the floor.

Inspectors wroteBased on medical record review and interview, the facility staff failed to thoroughly investigate a complaint of a neglect (Resident #35). This was evident for 1 out of 39 residents reviewed during a complaint survey.

Inspectors wroteBased on medical record review, administrative record review, and staff interviews, it was determined that the facility failed to protect a cognitively impaired resident (Resident #362) from physical abuse from a facility staff member on 5/15/22. This was evident for 1 of 29 residents (Resident #362) reviewed for abuse during an annual recertification survey. Resident #362 sustained a fall during a physically abusive incident and suffered a fractured hip. Thereafter, Resident #362 never regained his/her ability to walk independently. This failure to protect residents from physical abuse by facility staff members resulted in an Immediate Jeopardy. However, the facility developed, initiated, and completed an acceptable plan of correction to prevent further abuse which met all elements of past noncompliance. The period of noncompliance began on 5/15/22 and ended on 6/22/22. [...]

Inspectors wroteBased on observation, medical record review, and interview with staff it was determined that the facility failed to ensure residents received treatment and care in accordance with professional standards of practice as evidenced by 1.) failure to follow physician orders for 1 of 8 (Resident #155) residents reviewed for pressure ulcers, and 2 of 10 (Resident #40 and #19) residents reviewed for physician orders; 2.) failure of the GNA to notify the nurse after a resident had a fall for 1 of 5 (Resident # 609) residents reviewed for falls; 3.) failure of the facility to ensure that a resident received treatment for a possible wound infection for Resident #359, and 4.) failure to administer a pain medication for Resident #87 as ordered by the physician. This was found to be evident during the facility's annual Medicare/medicaid survey.

Inspectors wroteBased on observation, record review, and staff interview it was determined that the facility staff failed to store, prepare, and serve food and beverages using proper sanitary practices. This deficient practice has the potential to affect all residents in the facility.

Inspectors wroteBased on observation, medical record review and interviews, it was determined that the facility staff failed to provide an environment that promotes the dignity and respect for residents. This was found to be evident for Residents #16, #158, #37 and #362 and residents in Rooms #14, #18, #19, #20 sampled during the facility's annual Medicare/Medicaid survey.

Inspectors wroteBased on observations, record review, resident and staff interviews, it was determined that the facility staff failed to provide and maintain a safe, clean, and homelike environment for the residents. This was evident for 2 (3rd floor Dementia Unit and the Terrace Unit) of 4 units observed during the survey. Findings Includes: 1. A tour of the 3rd floor Dementia unit was conducted on 02/21/23 at 08:00 AM where a loose partially attached bumper panel on the left side of elevator door casing was observed. Multiple dark stains, black streaks, dents, and holes were noted on the lower portion of the unit's hallway. Further observation revealed folded candy wrappers located inside the handrail ledge near the unit's utility closet. An observation of the unit's dining room at 08:40 am revealed 5 dining chairs with their seat areas pushed in and frayed fabric dangling from their bottoms. [...]

Inspectors wroteBased on an administrative record review and interviews with the facility staff it was determined the facility failed to complete a thorough investigation into allegations of abuse. This was found to be evident for 4 (Residents #609, #42, # 356, and # 361) of 20 residents reviewed for abuse during the facility's annual Medicare/Medicaid survey.

Inspectors wroteBased on record review and staff interview it was determined that the facility failed to: 1.) ensure that a plan of care was adjusted to reflect significant weight loss for (Resident #60) reviewed for nutrition and 2.) revise care plans with appropriate goals and interventions for 2 (Resident #155 and Resident #178) of 8 residents reviewed for pressure ulcers, 2 (Resident #155 and Resident #188) of 5 residents reviewed for tube feeding, and 1 (Resident #188) of 3 residents reviewed for tracheostomy and 1 (Resident #178) 1 residents reviewed for anticoagulant therapy during the facility's annual Medicare/Medicaid survey process.

Inspectors wroteBased on record review, observation, and interview, it was determined that the facility staff failed to: 1.) administer a medication in accordance with the standards of practice for residents (Resident #87, #186, #117, #158, #84, #556) and 2.) document after medications were administered for residents (#172, #121, #155, #122, #188, #514 and #41). This was evident for 13 of 20 residents selected for review during a medication chart check during the facility's annual Medicare/Medicaid survey.

Inspectors wroteBased on QAPI record review and interview, the facility failed to adequately monitor its practices around abuse, specifically abuse prevention, abuse reporting, and abuse investigation. The facility had repeat deficiencies for abuse prevention, abuse reporting and abuse investigation during this annual survey after submitting a plan of correction in January 2022.

Inspectors wroteBased on observation, record review and interview, the facility failed to accommodate the needs of a resident by failing to ensure a resident had the medical equipment needed for their disability status. This was evident in 1 of 72 (Resident #103) residents reviewed during the facility's annual survey.

Inspectors wroteBased on observations and interviews with the resident and facility staff it was determined the facility failed to ensure that a newly admitted resident received breakfast the following morning after being admitted . This was found to be evident for 1 (Resident # 607) of 107 residents sampled during the facility's annual Medicare/Medicaid survey.

Inspectors wroteBased on medical record review and interviews it was determined that the facility failed to notify the physician when a resident refused medications that have the potential to adversely affect their health when missed. This deficient practice was evident in 1(Resident #107) of 5 medical records reviewed for physician notification.

Inspectors wroteBased on resident and staff interviews it was determined that the facility staff failed to report an allegation of verbal abuse to the state agency within two hours. This was evidenced in 1 (Resident #42) of 5 records reviewed for abuse.

Inspectors wroteBased on medical record review and interviews with facility staff it was determined the facility failed to ensure that the resident and or the resident responsible party (RP) received a written transfer notice with documentation of the reason for the transfer to the hospital prior to transfer. This was found to be evident for 3 (Residents #161, #166, and #556) of 4 residents reviewed for hospital transfers during the facility's annual Medicare/Medicaid survey.

Inspectors wroteBased on medical record review and interview with staff it was determined that the facility failed to have a system in place to ensure that residents or resident responsible party (RP) are given written notification of the facility bed-hold policy when they are being transferred out of the facility to a hospital. This was found to be evident for 3 (Residents #161, #166, and #556 ) of 4 residents reviewed for hospital transfers during the facility's annual Medicare/Medicaid survey.

Inspectors wroteBased on medical record review and interview with the facility staff it was determined that the facility failed to ensure Minimum Data Set (MDS) assessments accurately reflected the resident's status as evidenced by: 1.) failure to accurately code: speech, vision, hearing, health condition and pain for 1 (Resident #155) of 2 residents reviewed for pain; 2.) failure to accurately code a resident for falls for 1 (Resident #506) of 5 residents reviewed for falls and 3.) failure to accurately code a resident for bowel and bladder incontinence for 1 (Resident #163) out of 5 residents reviewed for bowel and bladder incontinence during the investigation stage of the survey.

Inspectors wroteBased on medical record review and interview with staff it was determined that the facility staff failed to develop a care plan to 1.) reflect the presence of and current treatment of the residents' behavior for 1 of 5 (Resident #188) residents reviewed for unnecessary medications; 2.) to reflect a resident who required staff to provide care and mobility for 1 out of 4 (Resident #155) reviewed for mobility and 3.) reflect the specific care for a resident who was admitted with a Foley catheter (Resident #410). This deficient practice was evident for 3 of 10 residents reviewed for care plans during the facility's annual Medicare/Medicaid survey.

Inspectors wroteBased on observation and interviews it was determined that the facility failed to follow the proper procedures to safely transfer a resident. This was evident for 1 of 8 residents (Resident #93) reviewed for accidents during the facility's annual Medicare/Medicaid survey.

Inspectors wroteBased on observation and interviews it was determined that the facility failed to maintain infection control practices. This deficient practice was evident in 2 (Resident #48 and #133) of 2 residents observed with urinary drainage bags and 1 treatment cart located on the Terrace Level.

Inspectors wroteBased on observation and interviews it was determined the facility failed to ensure all residents had access to a working call bell system. This deficient practice was evident in 1 of 7 (Resident #30) residents reviewed for a working call bell system.

Inspectors wroteBased on facility staff interviews with the DON (Director of Nursing) and record review, the facility failed to provide a written notice to a resident and the responsible party of the transfer for 3 out of 3 people reviewed for transfer out to the hospital.

Inspectors wroteBased on facility staff interviews with the DON (Director of Nursing) and record review, the facility failed to provide a written notice to a resident and the responsible party of the transfer for 3 out of 3 people reviewed for transfer out to the hospital.

Inspectors wroteBased on resident observation, responsible party and staff interviews it was determined that the facility staff failed to follow enteral feeding standards of practice. This was evident for 1 out of 2 residents selected for Tube Feeding review involving resident #105 during the investigative portion of the survey process. When a person cannot eat any or enough food because of an illness. Others may have a decreased appetite, difficulties in swallowing, or some type of surgery that interferes with eating. When this occurs, and one is unable to eat, nutrition must be supplied in a different way. One method is enteral nutrition or tube feeding. Risk of aspiration should be assessed individually and appropriate interventions (e.g., proper positioning, rate of flow) implemented accordingly.

Inspectors wroteBased on observation and staff interview it was determined that facility staff failed to treat residents with respect and dignified manner by knocking on resident's room doors before entering. This was evident for 2 out of 53 residents involving (R#105, and #192) observed during dining meal service.

Inspectors wroteBased on interview with resident, observation of resident and a review of medical records, the facility failed to identify a resident with Dental issues. This was evident for 1 out of 53 residents with dental issues.

Inspectors wroteBased on interview with resident, observation of resident and a review of medical records, the facility failed to identify a resident with Dental issues. This was evident for 1 out of 53 residents with dental issues.

Inspectors wroteBased on interview with resident, observation of resident and a review of medical records, the facility failed to identify a resident with Dental issues and a resident who is on dialysis. This was evident for 2 out of 53 residents without a base line care plan.

Inspectors wroteBased on interview with resident, observation of resident and a review of medical records, the facility failed to identify a resident with Dental issues and a resident who is on dialysis. This was evident for 2 out of 53 residents without a comprehensive care plan.

Inspectors wroteBased on observation and staff interviews it was determined that the facility staff failed to develop a care plan for Resident #119 with a diagnosis of dementia. This was evident for 1 out of 53 Residents investigated during the survey process. The Findings Include: On 04/05/19 around 09:21 AM, this surveyor was reviewing Resident #119's medical record. It was noted that the Resident has a diagnosis of dementia. Further review of the record revealed that there were no interventions in the care plan for a resident with cognitive difficulties. A Care Plan is a formal process that includes correctly identifying existing needs, as well as recognizing potential needs or risks. This allows nursing to identify interventions to assist the Resident with any barriers that interferes with the Resident's optimal level of health.