Inspection Reports for
Autumn Oaks Caring Center

Complaint number 2627706 triggered the investigation. The complaint involved failure to provide catheter care as ordered, resulting in potential urinary tract infections. The complaint was substantiated based on observations, interviews, and record reviews.

The facility failed to ensure catheter care was consistently provided and documented as ordered for one resident with an indwelling catheter, leading to potential risk of urinary tract infections. Multiple staff interviews and record reviews revealed incomplete documentation and inconsistent catheter care.

The complaint investigation was initiated after bruising was found on Resident #1 following a transfer with a gait belt. The resident's family was not notified of the bruising or subsequent x-ray and medication changes. The resident was transferred improperly using a hug technique instead of a gait belt, despite staff training and resident care needs. The resident bruised easily due to anticoagulant use and frail skin. The investigation concluded the facility failed to notify the family and failed to follow safe transfer protocols.

The facility failed to notify the resident's family representative timely about bruising and changes in condition, despite policy requirements. Additionally, the facility failed to properly care plan and safely transfer the resident, using inappropriate transfer methods such as hugging instead of gait belts, which posed a risk of injury.

The facility was found deficient in multiple areas including failure to issue accurate beneficiary notices, failure to refer residents for PASARR Level Two evaluations, incomplete care planning participation, inadequate pressure ulcer care and documentation, failure to prevent resident access to hazardous areas leading to choking, failure to follow up on significant weight loss interventions, lack of behavioral health services as required by PASARR Level II, failure to implement 14-day stop dates for PRN psychotropic medications, and failure to remove expired medications from medication carts.

The complaint investigation was substantiated with findings that the resident was left unsupervised in a staff break room with access to unsafe food items despite care plans and diet orders requiring supervision and pureed diet. The incident led to choking, emergency intubation, and hospitalization.

The facility failed to ensure the resident environment was free from accident hazards and did not provide adequate supervision during food consumption for Resident #36, leading to a choking incident requiring emergency intervention and intubation. The facility was initially cited at immediate jeopardy level but implemented corrective actions to remove the immediate jeopardy during the onsite visit.

The investigation was complaint-driven, focusing on catheter care deficiencies and lack of physician orders. The report indicates some residents were affected and minimal harm or potential for actual harm was identified.

The facility failed to ensure all residents with catheters received treatment and services to prevent urinary tract infections, including failure to document catheter care per physician's orders for three residents and failure to obtain physician orders for catheter use for one resident. Interviews and record reviews revealed inconsistent documentation and unclear adherence to catheter care policies.

The facility was found deficient in multiple areas including failure to maintain resident dignity with catheter care, failure to provide written bed-hold notices, improper administration of IV antibiotics, inadequate admission assessments leading to resident harm, failure to provide restorative nursing services as ordered, unsafe resident room environment due to hoarding, improper oxygen therapy management, failure to post nurse staffing information properly, improper medication storage temperatures, food safety violations, infection control lapses including improper mask use and glucometer disinfection, failure to document bed rail gap measurements, and lack of accessible call light cords in bathrooms.

The facility failed to maintain an effective infection control program as staff were observed not wearing masks properly or at all while in resident areas, despite policies requiring mask use. Multiple staff members were seen with masks below their nose or mouth or unmasked, posing a potential risk to residents.

The facility was found deficient in ensuring staff treated residents with dignity during feeding assistance, failed to provide proper rationale for continued use of PRN psychotropic medication beyond 14 days, and did not maintain proper food temperatures or serve beverages from dry glasses, potentially risking resident safety.