Autumn Woods Residential Health

Inspectors wroteBased on interview and record review, the facility failed to notify the responsible party of changes in the status of a resident's wounds for one resident of three resident's reviewed for notification of changes in resident health status.

Inspectors wroteThis citation pertains to Intake 2985599. Based on observation, interview, and record review, the facility failed to assess one resident (R806) for self-administration of medications out of two residents reviewed for self-administration of medications.

Inspectors wroteThis citation pertains to Intake number 2803493. Based on interview and record review, the facility failed to administer pain medication per physician order and resident preference for one (R900) of three residents reviewed for pain management.

Inspectors wroteThis citation pertains to intake 2626685. Based on interview and record review the facility failed to ensure interventions were implemented to monitor one resident (R901) of three reviewed for risk of elopement:

Inspectors wroteThis citation pertains to Intakes 1226813 and 2590504. Based on observation, interview and record review the facility failed to ensure call lights were in reach for four residents (R119, R160, R4 and R239) of six residents whose care needs were reviewed.

Inspectors wroteBased on observation, interview, and record review facility failed to honor a resident's preference for a room change for one resident (R184) of three residents reviewed for rights and preferences.

Inspectors wroteBased on interview and record review, the facility failed to ensure formulated advance directives were completed properly for one resident (R8) out of two reviewed for advanced directives.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain a homelike environment for two sampled residents (R151 and R184) of six reviewed for environment.

Inspectors wroteThis citation pertains to Intakes: 2578720, 2584022, 2586062 Based on interview and record review, the facility failed to thoroughly assess and document skin bruising for an injury of unknown origin for one resident (R50) of one reviewed for abuse.

Inspectors wroteBased on interview and record review, the facility failed to complete an annual pre-admission screening and resident review (PASARR) for one resident (R8) out of two reviewed for PASARR's. Findings Include:A review of the medical record revealed R8 was admitted into the facility on 5/5/2025 with the following medical diagnoses, Cerebral Infarction and Bipolar Disorder. A review of the most recent Minimum Data Set assessment revealed a Brief Interview for Mental status score of 14/15, indicating an intact cognition. R8 also required assistance with bed mobility and transfers. A review of the most recent PASARR was dated 6/28/2024. On 8/13/2025 at 11:23 AM, an interview was conducted with the Social Service Director (SSD) D. SSD D reported they would have to look and see if an annual was completed for R8. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement fall care plan interventions for one resident (R8) out of three reviewed for falls.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide routine finger nail care for two sampled residents (R16 and R20) of six reviewed for activities of daily living. R16On 8/12/2025 at 9:25 AM, R16 was observed in bed with long nails, with a yellowish tint, and a buildup of brown debris under them. R16 was asked if they preferred their nails at the observed length. R16 was observed to hold their hands up towards their face and expressed that the nails were long and that they should be cut. On 8/13/2025 at 9:40 AM, R16 was asked if the staff had cut their nails, R16 reported they had not been cut. R16's nails were observed in the same condition. On 8/13/2025 at 9:47 AM, Unit Manager, Licensed Practical Nurse (LPN A) was asked to observe R16's nails. LPN A expressed, R16's nails were long and needed to be cut. [...]

Inspectors wroteBased on interview and record review, the facility failed to schedule a hematology (specialty for diseases of the blood) appointment for one resident (R8) out of one reviewed for consultation appointments. Findings Include:On 8/13/2025 at 10:40 AM, R8 was observed in their bed. R8 stated they were doing okay, but their hands have been hurting them. A review of the medical record revealed R8 admitted into the facility on 3/7/2025 with the following medical diagnoses, Chronic Obstructive Pulmonary Disease and Obstructive Sleep Apnea. A review of the most recent Minimum Data Set assessment revealed a Brief Interview for Mental status score of 12/15, indicating an impaired cognition. R8 also required assistance with bed mobility and transfers. Further review of the medical record revealed an active order with a start date of 3/18/2025 for a hematology appointment follow up. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure timely monitoring for two ventilator residents (R3, R35) of four residents reviewed for respiratory care needs.

Inspectors wroteBased on interview and record review, the facility failed to provide mental health services in a timely manner for one resident (R186) out of three reviewed for mood and behavior.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure safe storage of medication for one resident (R149) of four residents reviewed for medication storage.

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly store a nebulizer mouthpiece for two residents (R6 and R191) out of two reviewed for nebulizer storage.

Inspectors wroteThis citation pertains to Intake MI00152547. Based on observation, interview, and record review, the facility failed to ensure a clean environment for one resident, (R702) of three residents reviewed for home-like environment.

Inspectors wroteThis citation pertains to Intake MI00148207. Based on observation, interview, and record review, the facility failed to maintain privacy from electronic devices (camera) located in the room of one resident (R704) of three reviewed for privacy.

Inspectors wroteThis citation pertains to Intake MI00147638 Based on interview, and record review, the facility failed to prevent verbal and physical abuse for one resident (R801) out of four reviewed for abuse.

Inspectors wroteBased on interview and record review, the facility failed to report an abuse allegation in a timely manner for one resident (R801) out of one reviewed for reporting. Findings Include: A review an investigation summary revealed the following, On 10/14/2024 at around 7:00 AM, Nurse D and Certified Nursing Assistant (CNA) E reported to ADON (Assistant Director of Nursing) . that they observed Licensed Practical Nurse (LPN) C yelling profanities at R801 for trying to sleep on the couch in the dayroom during their midnight shift on 10/13/2024 between 2:30am -3:30am. When R801 refused to get up off the couch LPN C continued to yell at them then got behind the couch and started lifting the couch to get R801 off. R801 then rolled onto the floor. Staff helped R801 up and took R801 to the room . A review of the initial report revealed that the incident was reported to the SA on 10/14/2024. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the sanitizer buckets, failed to ensure dishware was dry before stacking, and failed to ensure resident food items were dated. This deficient practice had the potential to affect all residents that consume food from the kitchen.

Inspectors wroteR79 Review of the facility record for R79 revealed an admission date of 12/26/24 with diagnoses that included Osteomyelitis of the Left Ankle and Foot and Chronic Obstructive Pulmonary Disease. On 07/23/24 at 10:58 AM, R79 reported they were bothered by their toenails being too long and needing to be trimmed and stated they could not recall seeing a Podiatrist since their admission to the facility. On 07/24/24 at 11:54 AM, R79's feet were observed with staff assisting to remove the bedding and socks. R79's toenails were excessively long on multiple toes including some sharp, unfiled corners and particularly on the bilateral great toes which were approximately one inch beyond the nail bed. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a Peripherally Inserted Central Catheter (PICC- An IV-Intraveneous line inserted via the veins in the arm) dressing was dated and documented when changed for two residents (R82, R131) of two reviewed for PICC line care.

Inspectors wroteThis citation pertains to Intakes M100144913 and M100145603. This citation had two deficient practice statements. Deficient practice statement #1. Based on interview, and record review, the facility failed to ensure a mechanical lift sling was in good repair and two trained staff were present during transfer to prevent a fall from a mechanical lift for one (R494) of one resident reviewed for falls, resulting in a hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store medication in a safe and secure manner for four (R97, R102, R11 and R33) of the 35 total sampled residents, reviewed for medication and storage.

Inspectors wroteBased on observation, interview, and record review, the facility failed to repair or replace a bed in disrepair for one (R136) of eight resident's reviewed.

Inspectors wroteThis citation pertains to Intake MI00142307. Based on interview, and record review the facility failed to follow up on medical appointments and consultations for skin for one resident (R904) of four residents reviewed for skin management.

Inspectors wroteThis citation pertains to Intake MI00142307. Based on interview, and record review the facility failed to complete wound care treatments as ordered for one resident (R904) of four residents reviewed for skin management.

Inspectors wroteThis citaiton pertains to Intake MI00139994. Based on interview and record review, the facility failed to administer prescribed pain mediations on multiple days for one resident (R703) out of two reviewed for medication administration. Findings Include: A review of the Intake noted the following, Complainant stated the resident was only given Tylenol when [R703] is supposed to be taking Morphine. A review of the medical record revealed that R703 admitted into the facility on 9/29/2023 with the following diagnoses, Pressure Ulcer of Sacral Region, Stage 4 (damage to deep skin tissue including tendons and nerves) and Alzheimer's Disease. A review of the Minimum Data Set (MDS) assessment revealed a Brief Interview for Mental Status score of 99, indicating severly impaired cognition. R703 also required extensive 1 person assist with bed mobility and transfers. [...]

Inspectors wroteThis citation pertains to Intake MI00139994. Based on interview and record review, the facility failed to initiate wound treatment for one resident (R703) out of one reviewed for wounds, resulting in the potential worsening of existing pressure ulcers and/ or development of new wounds. Findings Include: A review of the intake noted the following, Staff failed to change the dressing on the resident's wounds as ordered. When [R703] went home there was no dressing on [R703's] wound at all and it hadn't been cleaned. A review of the medical record revealed that R703 admitted into the facility on 9/29/2023 with the following diagnoses, Pressure Ulcer of Sacral Region, Stage 4 (damage to deep skin tissue including tendons and nerves) and Alzheimer's Disease. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure open food items were dated, ensure sanitizer test strips were available for use, ensure staff donned beard restraints, and ensure staff changed gloves to prevent cross contamination. This deficient practice had the potential to affect all residents that consume food from the kitchen.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that the resident's name, date, time, and order information for enteral feeding (Liquid nutrient solution fed through a PEG-Percutaneous Endoscopic Gastostomy tube inserted in through the stomach) was completed, for four (#'s R25, R42, R128, and R195) residents reviewed for tube feedings, resulting in the potential for tube feeding not administered according to the physicians orders.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medication refrigerators were maintained within an appropriate temperature range for two of four medication refrigerators and failed to ensure the resident identifier and date opened were labeled on the medication container when opened for three of five medications carts observed, resulting in the potential for the use of expired medication, inadvertent use of another residents medication and degraded medication.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that food was served in a palatable manner and at the preferred temperature for three residents (R39, R85, R139) and five confidential group residents of fifteen residents reviewed for palatable food, resulting in resident dissatisfaction during meals.

Inspectors wroteBased upon observation, interview and record review, the facility failed to implement the care plan for turning/repositioning frequency for five (R15, R114, R116, R131, R156) of seven residents reviewed for repositioning resulting in resident dissatisfaction with care, discomfort and potential for onset of or worsening of pressure ulcers.

Inspectors wroteThis citation pertains to Intake number MI00136364. Based on observation, interview, and record review the facility failed to administer medication to prevent seizures for one resident (R139) of one resident reviewed for medication administration, resulting in the potential for the resident to experience an increase in seizure activity and injury related to seizure activity.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a home-like environment for one resident, (R145) reviewed for homelike environment resulting in an unsanitary environment with wet and a buildup of dried tube feeding formula on the tube feeding pole and floor, and the potential for resident and resident representative dissatisfaction with their living conditions.