Autumnwood of McBain

Inspectors wroteBased on interview and record review, the facility failed to ensure safety during transport of one Resident (#10) of three residents reviewed for falls resulting in a fractured 1st cervical (neck) fracture, prolonged pain and fear of paralysis and failed to implement interventions for one Resident (#51) of one resident reviewed for handling of hot liquids, who was deemed unsafe to handle hot liquids without supervision and/or interventions in place.

Inspectors wroteBased on interview and record review, the facility failed to accurately code the Minimum Data Set (MDS) assessments of four Residents (R5, R1, R2, R3) of 18 residents reviewed for MDS accuracy.

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of neglect to the State Agency for one Resident (#10) of five residents reviewed for accident hazards and supervision.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide fingernail hygiene for one Resident (#66) of two residents reviewed for activities of daily living (ADL).

Inspectors wroteBased on interview and record review, the facility failed to ensure a comprehensive admission skin assessment was completed, pressure injuries were accurately identified and assessed upon admission, physician orders for treatments were timely obtained, and preventive measures were initiated without delay for one Resident (#104) of three residents reviewed for pressure injury prevention and treatment.

Inspectors wroteBased on interview and record review, the facility failed to ensure the physician reviewed medication orders for accuracy for one Resident (#3) of three residents reviewed for physician visits. This deficient practice resulted in Resident #3 experiencing a significant medication error and subsequent severe adverse effects.

Inspectors wroteBased on interview and record review, the facility failed to accurately transcribe and double check admission medications per standards of practice for one Resident (#3) of three residents reviewed for new admissions. This deficient practice resulted in Resident #3 experiencing a significant medication error and subsequent severe adverse effects.

Inspectors wroteBased on interview and record review, the facility failed to identify harmful dosing parameters and recognize the resulting side effects for an incorrectly prescribed thyroid medication for one Resident (#3) of 3 residents reviewed for .three residents reviewed for new admissions.

Inspectors wroteThis citation pertains to Intakes MI00150419 and MI00151063. Based on observation, interview, and record review, the facility failed to ensure adequate staffing to promote the physical, mental, and psychosocial well-being in 19 residents (#37, #51, #7, #87, #35, #36, #42, #48, #65, #81 and nine confidential residents) reviewed for staffing. This deficient practice resulted in actual harm for Residents #37, #7, #35, #42, and #48 who were forced to lay in their own excrement or urine for extended periods of time or delay a bowel movement due to insufficient staffing, resulting in reported feelings of frustration, helplessness, humiliation, and anger and/or inference of these feelings based on the reasonable person concept.

Inspectors wroteBased on observation and interview, the facility failed to store food in accordance with professional standards for food service safety as evidenced by: A. Failure to ensure expired food was discarded. B. Failure to ensure adequate labeling of potentially hazardous food. C. Failure to ensure cabinetry surrounding an ice machine was maintained in good repair. This deficient practice had the potential to result in food borne illness among any or all of the 89 residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure exhaust ventilation was functioning in resident bathrooms on one hall, serving 19 of a total 89 residents. This deficient practice resulted in noxious odors permeating the resident environment rendering the living conditions unpleasant and uncomfortable.

Inspectors wroteThis citation pertains to intake MI00150419. Based on observation, interview and record review, the facility failed to ensure residents were cared for in a dignified and respectful manner for five residents (#37, #51, #7, #38 and #2) of five residents reviewed for dignity, resulting in feelings of frustration, humiliation and low self-worth based on a reasonable person standard.

Inspectors wroteThis deficient practice pertains to intake MI00151063. Based on observation, interview, and record review, the facility failed to provide activities of daily living (ADL) care for six dependent Residents (#35, #36, #42, #48, #65, and #81) out of 19 residents reviewed for personal hygiene and incontinence care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to 1. Obtain physician orders and administer oxygen at the prescribed flow rate, and; 2. Ensure respiratory equipment was changed, labeled, stored, and cleaned appropriately; for eight Residents (#243, #43, #3, #240, #245, #88, #44, and #18) of eight residents reviewed for oxygen and respiratory equipment services.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain a medication error rate below 5% for two Resident (#11 & #26) of nine residents reviewed for medication administration. This deficient practice resulted in 2 medication errors out of 31 opportunities for error with a medication error rate of 6.4%. Findings Include: Resident #11 (R11) R11 was admitted to the facility on [DATE] with a primary diagnosis of osteoarthritis (a degenerative disease of the joints). Review of R11's physician orders revealed an order dated 10/13/24 that read: Tylenol 8 Hour Arthritis Pain Oral Tablet Extended Release 650 mg (milligrams): Give 1 tablet by mouth three times a day for Arthritis pain. On 3/24/25 at 12:33 PM, Licensed Practical Nurse (LPN) O was observed preparing medications to administer to R11. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to dispose of expired medications and ensure required medications were dated when opened on two medication carts of three medication carts reviewed for medication storage and labeling.

Inspectors wroteBased on observation and interview, the facility failed to ensure meals were served at a palatable and appetizing temperature for two Residents (#51, #71) of two residents reviewed for food palatability, and nine out of 10 residents from the confidential group meeting, resulting in decreased meal satisfaction and the potential for decreased food acceptance and nutritional decline.

Inspectors wroteBased on observation, interview, and record review, the facility failed to 1. Perform hand hygiene at appropriate opportunities for hand hygiene related to meal service and medication administration, 2. Appropriately don and doff disposable single use gloves, 3. Ensure contaminated ice was discarded. 4. Rinse and dry respiratory treatment equipment between medication treatments, 5. Maintain a sanitary medication cart, and 6. Ensure Infection Control Polices are update at least annually.

Inspectors wroteThis citation pertains to Intake MI00151063. Based on interview and record review, the facility failed to ensure a safe community discharge for one Resident (#76) of three residents reviewed for transfer and/or discharge. This deficient practice resulted in fear, distress, and feelings of helplessness regarding a safe discharge location.

Inspectors wroteBased on interview and record review, the facility failed to notify the resident and/or resident representative in writing with the reason for a transfer out of the facility for two Residents (#6 and #51) of three residents reviewed for transfer and/or discharge.

Inspectors wroteBased on interview and record review, the facility failed to ensure written information was provided to two Residents/Representatives (#6 and #51) of three residents reviewed for written notification of bed hold.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a comprehensive, person-centered care plan related to ostomy care for two Residents (#37 and #12) of two residents reviewed for comprehensive care planning, resulting in the potential for untimely, and unmet care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure functional positioning during mealtimes for one Resident (#25) of two residents reviewed for positioning.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement interventions and prevent the development of a pressure ulcer for one Resident (#42) of five residents reviewed for pressure ulcers.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure smoking paraphernalia was stored in a secure location for one Resident (#25) of three residents reviewed for accidents, hazards, and supervision.

Inspectors wroteBased on interview and record review, the facility failed to maintain an effective vaccination program for three residents (R28, R42, and R48) of five residents reviewed for vaccinations.

Inspectors wroteBased on observation, interview, and record review, the facility failed to train a non-licensed employee with the State-approved training course for feeding assistance to residents. This deficient practice resulted in an increased risk of feeding complications for all 3 residents requiring assistance during mealtimes.

Inspectors wroteBased on observation, interview, and record review the facility failed to employ sufficient staff with the appropriate competencies and skills to carry out the functions of the food and nutrition services.

Inspectors wroteBased on interview and record review, the facility failed to ensure written information was provided to five Resident/Representatives (#3, #5, #76, #332, #333) of six reviewed for written notice of bed hold.

Inspectors wroteBased on interview and record review, the facility failed to ensure a recapitulation of stay was completed for one Resident (#10) out of two closed records reviewed for discharge documentation. Findings Include: Resident #10 (R10) Review of R10's most recent Minimum Data Set (MDS) Assessment, dated 2/1/24, revealed admission to the facility on 7/27/23, with diagnoses including bipolar disorder, major depressive disorder, suicidal ideations, and post-polio syndrome (a condition that causes gradual muscle weakness and muscle loss). R10 was discharged from the facility on 3/28/24. Review of R10's EMR revealed no discharge plan or recapitulation of stay. On 4/17/24 at 9:39AM, an interview was conducted with Social Service Director G who confirmed no post-discharge summary or recapitulation of stay was completed because R10 discharged to a different skilled nursing facility. [...]