Audubon Health and Rehab

In the surveyor’s words

From the most serious findings on record at Audubon Health and Rehab, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF580Sep 28, 2023

  Based on record reviews, observations, and interviews the facility: 1. Failed to notify a resident's physician of a change in a resident's condition for 3 (Resident #44, Resident #67, and Resident #87) of 25 residents included in the final resident sample; 2. Failed to notify a resident's responsible party of a change in condition for 2 (Resident #44 and Resident #87) of 25 residents included in the final resident sample; and, 3. Failed to notify a resident's hospice agency of a change in condition for 1 (Resident #87) of 25 residents included in the final resident sample. […]

• No harm, potential for more than minimal, patternF880Sep 28, 2023

  Based on observations, interviews, and record review the facility failed to ensure: 1. Staff performed hand hygiene per facility policy during catheter care for 1 (Resident #87) of 2 residents (Resident #30 and Resident #87) investigated for catheters; 2. Staff performed hand hygiene per facility policy while serving meal trays to residents in their rooms; and 3. Staff handled soiled linen in a manner to prevent cross contamination of surfaces when 2 Certified Nursing Assistants (CNAs) (S16CNA and S21CNA) placed soiled linen on the floor for 2 (Resident #44 and Resident #87) of 2 residents observed during perineal care (washing the genital and rectal areas of the body) and 1 CNA(S21CNA) placed items used in a resident's room onto the clean linen cart. […]

• No harm, potential for more than minimal, isolatedF627Sep 18, 2025

  Based on interviews and record reviews, the facility failed to ensure a resident was included in the discharge planning process for 1 (Resident #8) of 3 (Resident #8, Resident #118, Resident #120) sampled residents investigated for discharge requirements.Findings:Review of the facility's Discharge Transfer and Planning policy, last revised in 08/2025, revealed, in part, discharge planning shall be initiated by the Social Service Director/Designee with anticipated discharges. Further review revealed the discharge plan shall focus on the residents' discharge goals and the preparation of residents to be active partners for post discharge care. Further review reveled the IDT would include regular re-evaluation of residents to identify changes that required modification of the discharge plan. […]

• No harm, potential for more than minimal, isolatedF880Sep 18, 2025

  Based on observations, interviews, and record reviews, the facility failed to ensure staff wore proper personal protective equipment (PPE) during personal hygiene care for a resident on Enhanced Barrier Precautions (EBP) (an infection control strategy that used gloves and gowns during high-contact resident care to reduce to spread of infection) for 1 (Resident #39) of 8 (Resident# 2, Resident #5, Resident #9, Resident #11, Resident #27, Resident #39, Resident #67, Resident #69) sampled residents who required EBP. Findings:Review of the facility's EBP policy and procedure, dated 01/2023 and revised on 03/2024, revealed, in part, EBP required the use of a gown and gloves for high contact resident care activities such as providing personal hygiene care. […]

• No harm, potential for more than minimal, isolatedF689Sep 25, 2024

  Based on observations, interviews, and record reviews the facility failed to ensure residents did not have cigarette lighters in their possession and/or rooms for 2 (Resident #32 and Resident #79) of 2 (Resident #32 and Resident #79) sampled residents reviewed for accidents and hazards while smoking. Findings: Review of the facility's Smoking Policies and Regulations dated October 2022 revealed, in part, this policy and procedure was developed to ensure the safety of the residents. Further review revealed cigarette lighters were not permitted in a resident's room and would be kept at the nurses stations. Further review revealed adherence to this policy and procedure would be strictly enforced. […]