Autumn Oaks Caring Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all residents with catheters (a sterile tube inserted into the bladder to drain urine) received treatment and services in a manner to prevent urinary tract infections (UTI) when staff failed to document providing catheter care per physician's orders for one resident (Residents #1). A sample of four residents was reviewed in a facility with a census of 76. Review showed the facility did not provide a policy regarding catheter care. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed provide timely notification to each resident family member/representative when staff failed to notify the family of one resident (Resident #1) after significant bruising was identified on the resident resulting in an ordered x-ray and temporary medication changes. The facility census was 65. Review of the facility's current policy titled Change in a Resident's Condition or Status, dated February 2021, showed the following: -The facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status; -Unless otherwise instructed by the resident, a nurse will notify the resident's representative when, the resident is involved in any accident or incident that results in an injury including injuries of an unknown source; [...]

Inspectors wroteBased on interview and record review, the facility failed to keep all residents free from possible accident hazards, when staff failed to transfer one resident (Resident #1) in a manner to prevent possible injury and failed to care plan regarding the resident's transfer needs/preferences. The facility had a census of 65. Review of the facility's policy titled Safe Lifting and Movement of Residents, dated revised July 2017, showed the following: -In order to protect the safety and well-being of staff and residents, and to promote quality of care, this facility uses appropriate techniques and devices to lift and move residents; -Nursing staff in conjunction with the rehabilitation staff shall assess individual residents needs for transfer assistance on an ongoing basis; -Staff responsible for direct resident care will be trained in the use of manual (gait/transfer belts); [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the residents environment was free from accident hazards as possible and failed to ensure all residents that required supervision during food consumption were supervised for one resident (Resident #36), of five sampled residents, when staff left the resident, who had an ordered pureed diet and was care planned for supervision while eating, access to an non-resident use area with food, resulting in the resident attempting to consume non-pureed food, choking, and being intubated. The facility census was 67. The facility Administrator, Director of Nursing (DON), and Regional Nurse Consultant were informed on 01/07/25, at 7:05 P.M., the an Immediate Jeopardy (IJ) which began on 01/03/25. The IJ was removed on 01/08/25 as confirmed by surveyor onsite verification. [...]

Inspectors wroteBased on interview, observation, and record review, the facility failed to provide care and services to maintain acceptable parameters of nutritional status, when staff failed to follow-up on and implement multiple weight loss interventions for one resident (Resident #2), of nine sampled residents reviewed for weight loss, who had a significant weight loss. The facility census was 67. 1. Review of Resident #2's admission Record, located under the Profile tab of the electronic medical record (EMR), showed the resident admitted on [DATE]. [...]

Inspectors wroteBased on interview and record review, the facility failed to issue accurate and fully completed Skilled Nursing Facility Advanced Beneficiary Notices (SNFABN) to one resident (Resident #49) of three sampled residents reviewed for beneficiary notice. The facility census was 67. Review of Resident #49's electronic medical record (EMR) Census tab showed an admission date of 04/04/23 for Medicare A services. Review of a document titled, Beneficiary Notice - Residents discharged Within the Last Six Months, completed by the facility and listing the residents who had been discharged from skilled services, showed the following: -The resident received an SNFABN on 08/13/24. -The resident chose Option One, I want the care listed above. I want Medicare to be billed for an official decision on payment which will be sent to me on a Medicare Summary Notice (MSN). [...]

Inspectors wroteBased on interview and record review, the facility failed to refer one resident (Resident #4) of two sampled residents for a Pre-admission Screening and Resident Review (PASARR) Level Two evaluation after the resident was diagnosed with a serious mental illness (SMI). The facility census was 67. Review of the facility's policy titled, admission Criteria, revised March 2019, showed all new admissions and readmissions are screened for mental disorders, intellectual disabilities or related disorders per the Medicaid PASARR process. The policy did not address the process when a new serious mental illness diagnosis is given to a resident. Review of Resident #4's admission Record, undated, located in the resident's electronic medical record (EMR) under the Profile tab, showed the following: -admission date of 12/03/21; -readmission date of 07/07/24; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents and their representatives were invited to the care plan meeting and failed to ensure the full Interdisciplinary Team (IDT) participated in the care conferences for one resident (Resident #11) of three sampled residents reviewed for care planning. The facility census was 67. Review of the facility's policy titled, Care plans, Comprehensive Person-Centered, dated March 2022, showed the following: -The IDT, in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person centered care plan for each resident; -If the participation of the resident and his/her resident representative in developing the resident's care plan is determined to not be practicable, an explanation is documented in the resident's medical record. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident pressure ulcer care and preventions was provided per standards of practice, when the facility failed to consistently assess and document full assessments of a pressure ulcer, failed to care plan and implement preventative measures related to pressure ulcer development, and failed to ensure the wound care provider was notified and provided care for the a known pressure ulcer, for one resident (Resident #4). The facility also failed to accurately document regarding a pressure ulcer and provide ordered pressure reducing interventions for one resident (Resident #31). The facility census was 67. Review of the facility's policy titled, Pressure Ulcers/Skin Breakdown-Clinical Protocol, revised March 2014, showed the following: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure behavioral health services were provided for one resident (Resident #64) of two sampled residents reviewed for PASARR Level II. The facility census was 67. Review of the facility's policy titled, Behavioral Health Services, revised February 2019, showed the following: -The facility will provide and residents will receive behavioral health services as needed to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care; -Behavioral health services are provided to residents as needed as part of the interdisciplinary, person-centered approach to care; -Residents who exhibit signs of emotional/psychosocial distress receive services and support that address their individual needs and goals for care; [...]

Inspectors wroteBased on interview and record review, the facility failed to implement a 14 day stop date for the as needed (PRN) use of an anti-anxiety medication and/or provide a rationale for the continued use of the medication for two residents (Resident #39 and #64) of two residents reviewed for anti-anxiety medications. The facility census was 67. Review of the facility's policy titled, Medication Utilization and Prescribing - Clinical Protocol, dated July 2016, showed the following: -When a medication is prescribed in response to an identified problem, condition, or risk, the physician and staff will identify the indications (condition or problem for which it is being given, or what the medication is supposed to do or prevent), considering the resident's age, conditions, risks, health status, and existing medication regimen. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store medications per standards of practice when staff failed to remove expired medications from the a medication cart that contained current medications to be administered to residents The facility census was 67. Review of the facility's policy titled, Medication Labeling and Storage, dated February 2023, showed the following: -The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner; -If the facility has discontinued, outdated, or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all residents with catheters (a sterile tube inserted into the bladder to drain urine) received treatment and services in a manner to prevent urinary tract infections (UTI) when staff failed to document providing catheter care per physician's orders for three residents (Residents #1, #2, and #3) and failed to obtain a physician's order for a catheter for one resident (Resident #1). Two resident (Resident #1 and #3) had a history of UTIs. A sample of five residents was reviewed in a facility with a census of 75. Review of the facility's Catheter Care, Urinary Policy, revised August 2022, showed the following information: -Purpose of the procedure was to prevent urinary catheter-associated complications, including urinary tract infections; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care in accordance with professional standards when facility staff failed to complete a full assessment and monitor a newly admitted resident (Resident #53), who experienced labored breathing and passed away after arrival to the facility. A sample of 21 residents was reviewed in a facility with a census of 57. The Administrator, Director of Nursing (DON), Regional Nurse, and Corporate Director of Operations were notified on [DATE], of the Past Non-Compliance which occurred on [DATE]. On [DATE], the DON reviewed the resident's chart and began an investigation, educated the employees involved, in-serviced all facility staff, and is monitoring charts daily to ensure all admission assessments are being completed timely. The noncompliance was corrected on [DATE]. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was stored, prepared, and distributed in a manner to prevent possible contamination when staff failed to maintain food contact services as clean and failed to dispose of foods with expired dates. This had the potential to affect all residents who consumed food from the facility kitchen. The facility census was 57. 1. Review of the 2013 Missouri Food Code showed food-contact surfaces of equipment and utensils shall be clean to sight and touch. Review of the facility's policy titled Sanitization Policy, revised November 2022, said the following: -All kitchens, kitchen areas, and dining areas are kept clean, free from garbage and debris, and protected from rodents and insects; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all residents were cared for in manner that provided dignity and respect when staff failed to ensure catheter (tubing to drain the bladder) collection bags were placed inside a dignity bag (bag which prevents urine from being seen) for four residents (Residents #14, #25, #47, and #257). A sample of five residents with indwelling catheters were reviewed in a facility with a census of 57. Review of the facility's policy entitled Catheter Care, Urinary, revised August 2022, showed the policy did not include information pertaining to a dignity bag/cover for the collection bag. Review of a facility's policy entitled Dignity, revised February 2021, showed the following information: -Residents are treated with dignity and respect at all times; [...]

Inspectors wroteBased on interview and record review, the facility failed to give written information to the resident and/or resident's representative of the facility's bed hold policy for four residents (Residents #14, #29, #25, and #17) who were transferred out to the hospital. A sample of 21 residents were reviewed in the facility with a census of 57. Review of the facility's policy entitled Bed-Holds and Returns, revised October 2022, showed the following: -All residents/representatives are provided written information regarding the facility and state bed-hold policies, which address holding or reserving a resident's bed during periods of absence (hospitalization or therapeutic leave). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide restorative nursing services to maintain or improve residents' functional status as directed by therapy for three residents (Residents #44, #43, and #46) out of 21 sampled residents. The facility census was 57. Review of the facility's policy, Restorative Nursing Services, undated, showed the following information: -Residents will receive restorative nursing care as needed to help promote optimal safety and independence; -Restorative nursing care consists of nursing interventions that may or may not be accompanied by formalized rehabilitative services (e.g., physical, occupational or speech therapies); -Residents may be started on a restorative nursing program upon admission, during the course of stay, or when discharged from rehabilitative care; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain physician's orders directing staff when to change oxygen tubing, failed to have documentation of when the oxygen tubing was changed, and failed to date the oxygen tubing when last changed for three residents (Residents #23, #25, and #14); failed to care plan oxygen use for two residents (Residents #23 and #14); and failed to keep the humidifier bottle filled for one resident (Resident #25). A sample of four residents that used supplemental oxygen were selected in a facility with a census of 57. Review of the facility policy titled Oxygen Administration, revised October 2010, showed the following: -The purpose of the policy is to provide guidelines for safe oxygen administration; [...]

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to store refrigerated medications at the medication's recommended temperatures and failed to have a system in place to monitor and adjust the temperature as needed. The facility census was 57. Review of the facility's policy titled Storage of Medications, dated November 2020, showed the following: -The facility stores all drugs and biologicals in a safe, secure, and orderly manner; -Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light, and humidity controls; -Medications requiring refrigeration are stored in a refrigerator located in the drug room at the nurses' station or other secured locations. Medications are stored separately from food and are labeled accordingly. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to use appropriate infection control procedures to prevent the spread of bacteria or other infectious carrying contaminants when staff failed to follow the facility's infection control policy when staff did not wear face masks throughout the facility when three residents (Residents #1, #10, and #29) tested positive for COVID-19 in the facility; when the facility failed to ensure staff followed acceptable standards of practice for infection control when they did not properly clean and disinfect glucometers (digital machine used to test the glucose/sugar level in blood) for two randomly observed residents (Residents #27 and #37); when staff failed to complete hand hygiene with insulin administration for one resident (Resident #27) of six sampled resident who received insulin; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to complete and document regular inspection of all bed frames to include safety gap check measurement for four residents (Residents #256, #257, #25, and #47) out of a sample of four residents with bed rails. The facility census was 57. Review showed the facility did not provide a policy regarding checking measurements of beds when bed rails were applied. 1. Review of Resident #256's face sheet showed the following information: -admission date of 05/16/23; -Diagnoses included osteomyelitis of vertebra, sacral and sacrococcygeal region (inflammation of the spine caused by infection). Review of the resident's current Physician Order Sheet (POS) showed an order, dated 05/23/23, for the resident to have a bed assist rail to side of bed for improved positioning and increased independence. [...]

Inspectors wroteBased on observation and interview, the facility failed to provide a sanitary environment for all staff when the dietary and maintenance staff failed to ensure three fans located in the walk-in refrigerator were cleaned. The facility census was 57. Review of the facility's policy titled Sanitization Policy, revised November 2022, said the following; -All kitchens, kitchen areas, and dining areas are kept clean, free from garbage and debris, and protected from rodents and insects; -All utensils, counters, shelves and equipment are kept clean, maintained in good repair and are free from breaks, corrosions, open seams, cracks and chipped areas that may affect their use or proper cleaning. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care that met professional standards of quality when staff did not administer an IV (intravenous - means giving medicines or fluids through a needle or tube (catheter) that goes into a vein) antibiotic with the ordered amount of saline solution for one resident (Resident #25) out of a sample of 21 residents. The facility census was 57. Review of the facility's policy Administering Medications, dated April 2019, showed the following: -Medications are administered in a safe and timely manner and as prescribed; -Medications are administered in accordance with prescribed order, including any required time frame. 1. Review of Resident #25's face sheet (gives basic profile information) showed the following information: -admission date of 01/13/23 with readmission date of 03/14/23; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an environment free of accident hazards and the ability for staff to provide timely emergency care for one resident (Resident #8) of 21 sampled residents. Resident #8's room had items on the floor and throughout the room that prevented the resident's bed from being accessible except for crawling in and out of the end of the bed. The facility census was 57. 1. Review of Resident 8's face sheet (gives basic profile information) showed the following: -admission date of 08/25/20 with readmission date of 03/27/23; -Diagnoses included acute kidney failure (kidneys unable to filter waste products), major depressive disorder (persistent feelings of sadness), high blood pressure, and benign prostatic hyperplasia (enlarged prostate) with lower urinary tract (urinary infection). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure call light cords were available to residents at all times when there was no cord for the call light in the shared bathroom for two residents (Residents #23 and #40). Twenty-one residents were sampled in a facility with a census of 57 residents. Review of a facility's policy and procedure entitled Call System, dated September 2022, showed the following information: -Residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member or centralized work station; -Each resident is provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities, and from the floor; -The resident call system remains functional at all times; [...]

Inspectors wroteBased on observation and interview, the facility failed to post daily nurse staffing information, that included the total number of staff and total number of hours worked per shift, in a prominent place, readily accessible to residents and visitors. The facility census was 57. Review of a facility policy entitled Posting Nursing Staffing Information undated, showed the following: -Current federal regulations mandate that the facility posts a form daily at the beginning of each shift in a prominent place readily accessible to residents and visitors in a clear and readable format with facility name, current date, total number and actual hours worked by licensed and unlicensed staff directly responsible for resident care per shift, and resident census. The hours are separated by registered nurses (RN), licensed practical nurses (LPN), and Certified Nursing Assistants (CNA). [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure potentially hazardous food was maintained at the proper temperature and failed to serve beverages from dry glasses. This could lead to food contamination and potentially affect all residents. The facility census was 51. 1. Record review of the 2013 Food Code, published by the Food and Drug Administration, showed that except for during preparation, cooking, or cooling, control of food temperature shall be maintained at or above 135 degrees Fahrenheit (F) for hot foods, and at or below 41 degrees F for cold foods. Record review of the 2016 facility policy titled Monitoring Food Temperatures for Meal Service, showed the following: -Food temperatures will be monitored daily to prevent food borne illness and ensure foods are served at palatable temperatures; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff treated each resident with respect and dignity when staff stood over one resident (Resident #30) while assisting the resident to eat. The facility census was 51. 1. Record review of Resident #30's quarterly Minimum Data Set (MDS - a federally mandated comprehensive assessment tool completed by facility staff), dated 9/17/19, showed the following information: -readmitted to the facility from a hospital on [DATE]; -Diagnoses included dementia, schizoaffective disorder (a chronic mental health condition characterized primarily by symptoms of schizophrenia, such as hallucinations or delusions, and symptoms of a mood disorder, such as mania and depression), anxiety, type diabetes II, dysphagia (difficulty swallowing), paraplegia, and depression; [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a medication regimen free from unnecessary medication when the facility failed to provide rationale to continue an as needed (PRN) psychotropic (any drug that affects brain activities associated with mental processes and behavior) medication past 14 days for one resident (Resident #30) in a selected sample of 13. The facility census was 51. Record review of the facility's policy titled Antipsychotic Medication Use, dated December 2016, showed the following: -The need to continue PRN orders for psychotropic medications beyond 14 days requires that the practitioner document the rationale for the extended order. -Residents will not receive PRN doses of psychotropic medications unless that medication is necessary to treat a specific condition and is documented in the clinical record. 1. [...]