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 facility failed to provide timely notification to resident family members regarding significant changes such as bruising and did not ensure residents were free from accident hazards during transfers. The facility also failed to document notification of the resident representative and did not follow proper procedures for gait belt use and resident transfers.

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 to be in compliance with 42 CFR 483.73 for Emergency Preparedness but was found to be in noncompliance with Life Safety Code requirements related to discharge from exits. Specifically, one exit discharge did not have a hard surface to the public way, potentially affecting 14 residents.

The facility failed to maintain a surety bond sufficient to cover resident funds as required by state regulations. The bond amount was $33,000 but needed to be at least $34,500 based on the average monthly balance of resident funds.

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 survey was a Recertification and Complaint Survey. The facility was found not in substantial compliance with 42 CFR 483 subpart B. The Immediate Jeopardy level deficiency was related to accident hazards and supervision for one resident.

The facility was found not to be in substantial compliance with federal regulations. Deficiencies were cited related to Medicaid/Medicare coverage notices, PASARR coordination, care plan timing and revision, pressure ulcer treatment and prevention, accident hazards supervision, medication labeling and storage, psychotropic medication use, and behavioral health services.

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 facility failed to ensure all residents with catheters received proper treatment and services to prevent UTIs. Staff did not consistently document catheter care or obtain physician orders for catheter use, leading to deficiencies in care for multiple residents.

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 failed to maintain the integrity of building construction related to fire safety, including unsealed penetrations in ceilings, lack of self-closing doors in hazardous areas, sprinkler system maintenance issues, and electrical receptacle safety concerns. These deficiencies had the potential to affect residents, staff, and visitors in the event of a fire.

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 infection control program that ensured staff wore face coverings properly while working with residents, leading to multiple observations of staff and residents not wearing masks correctly or at all.

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 failed to ensure all allegations of possible abuse were reported within two hours to the State Survey Agency as required. Interviews and record reviews showed staff did not promptly report an allegation of abuse involving a Social Services Director and a resident.

The facility failed to provide written notice to a resident's representative regarding a room change before moving the resident. The facility also failed to notify representatives of residents in a timely manner when residents had changes in condition including falls.

The facility failed to ensure the availability and administration of Vitamin A and Effexor to Resident #1, resulting in medication errors. Documentation and communication regarding medication orders and administration were incomplete or missing.

The investigation was triggered by allegations of resident-to-resident verbal and physical abuse. The facility was found to have failed to report and investigate these allegations timely and properly. The complaint was substantiated with multiple violations related to abuse reporting and investigation.

The facility failed to report multiple allegations of resident-to-resident verbal and physical abuse in a timely manner to the State Survey Agency and Department of Health and Senior Services. The facility also failed to transcribe and document completion of physician-ordered treatment for a resident with arterial ulcers and failed to timely assess and treat pressure ulcers.

The facility failed to ensure the activities program director met the required qualifications and training. The activities program did not meet regulatory standards as the director was not certified or formally trained as required.

The facility was found deficient in treating residents with respect and dignity, ensuring safe and appropriate use of psychotropic medications, and maintaining food safety standards including proper food temperatures and sanitary practices.

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.

The facility failed to maintain proper egress door locking arrangements, failed to install a manual fire alarm pull station in a required location, and did not maintain sprinkler system coverage and maintenance as required by NFPA standards. These deficiencies posed potential risks to resident safety in the event of a fire.

The complaint investigation was substantiated. The facility failed to provide required Medicare notices, did not report abuse allegations timely, and had deficiencies in dialysis care and resident call system compliance.

The facility failed to provide required Medicare Provider Non-Coverage notices to residents, did not report allegations of abuse within required timeframes, and failed to provide thorough dialysis assessments and documentation. Additionally, the facility lacked a fully functional resident call system in all toilet rooms.

The facility failed to maintain emergency lighting as required by the 2012 Life Safety Code. Three emergency lighting devices were found inoperable, potentially affecting residents, staff, and visitors during a power outage.

The complaint investigation was substantiated based on findings that the facility failed to administer medication as ordered and failed to properly document and notify regarding missed doses.

The facility failed to administer medication as ordered to one resident, with documentation showing missed doses and lack of proper notification or explanation for the missed medication. Interviews with staff and the Director of Nursing revealed delays and communication issues related to medication administration.