Autumn Care of Nash

In the surveyor’s words

From the most serious findings on record at Autumn Care of Nash, in the surveyor’s own words.

• Actual harm, isolatedF578Jul 20, 2021

  Based on record review, staff, hospice, and emergency medical services (EMS) interviews the facility failed to clarify code status resulting in a transfer to hospital and intubation for 1 of 3 residents reviewed for advance directives (Resident #1). Findings included: Resident #1 was admitted to facility on 04/22/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan initiated on 04/27/21 revealed Resident #1 was a full code. The most recent Minimum Data Set (MDS) dated [DATE] revealed Resident #1 was cognitively impaired and was not on hospice service. […]

• Actual harm, isolatedF684Jul 20, 2021

  Based on interviews of facility staff, hospice, physician and emergency medical technician, and record reviews, the facility failed to provide oxygen for one of one resident who had an oxygen saturation rate of 69% that decreased to 50-60 %. (Resident #1). Findings included: Resident #1 was admitted to facility on 04/22/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Physician Standing Orders dated 04/25/17 revealed oxygen to be administered at 2 liters per minute by nasal cannula or mask for respiratory distress and to notify physician as soon as possible. […]

• Actual harm, isolatedF849Jul 20, 2021

  Based on record review, staff, hospice and emergency medical technician interviews, the facility failed to notify Hospice of a Residents acute change in condition resulting in an unnecessary transfer to the hospital and intubation for 1 of 1 sampled resident. (Resident #1) Findings Include: Record review of the Hospice Nursing Facility Services Agreement dated [DATE] revealed in section: Monitoring of Residential Hospice Patient Nursing facility shall immediately inform Hospice of any change of condition of a Residential Hospice Patient. Patient Transfer Nursing facility agrees not to transfer any Residential Hospice Patient to another care setting without the prior approval of hospice. Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, patternF812Feb 10, 2022

  Based on observation, and staff interview the facility failed to maintain the kitchen clean and in a sanitary condition to prevent food borne illness by failing to clean one of one steam table shelves and failed to degrease baking sheets. The findings included: During the initial tour on 2/14/22 at 9:35 AM three baking sheets, were observed on top of the convection oven. The sheet pans had a buildup of dried food particles/grease under the 1-inch rim. On 2/17/22 at 9:09 AM 2 sets of baking sheets nested rolls to proof, were observed warming on top of the convection oven. The sheet pans had a buildup of dried food particles/grease under the 1-inch rim. One rolling cart with 6 sheet pans stored upside to dry was observed. […]

• No harm, potential for more than minimal, patternF814Feb 10, 2022

  Based on observation, policy review and staff interview the facility failed to maintain the area surrounding the dumpster free of debris for 2 of 2 dumpsters observed. The findings included: During an observation of the dumpster area on 2/16/22 at 1:34 PM, 2 disposable gloves, and assorted papers were observed beside dumpster # 1. A Styrofoam cup, assorted papers, straw papers, 2 empty plastic drink bottles, and jelly cup were observed behind dumpster #1 and dumpster # 2. During an observation of the dumpster area on 2/17/22 at 8:15 AM, 3 disposable gloves, and assorted papers were observed beside dumpster # 1. One Styrofoam cup, assorted papers, straw papers, 2 empty plastic drink bottles, and jelly cup were behind dumpster #1 and dumpster # 2. […]