Autumn Creek Post Acute

In the surveyor’s words

From the most serious findings on record at Autumn Creek Post Acute, in the surveyor’s own words.

• Actual harm, isolatedF689Oct 27, 2025

  Based on interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for one of two residents (Resident 1) sampled for falls. Resident 1 had four unwitnessed falls in seven days, three occurring after an indwelling catheter (a soft tube that is inserted into the bladder and allows urine to drain into a collection bag) was not replaced and contributed to Resident 1's falls by her attempting to toilet herself. […]

• Actual harm, isolatedF686Jul 24, 2025

  Based on interview and record review, the facility failed to develop and implement a plan of care to prevent pressure injuries (damage to the skin and underlying tissue, usually over a bony prominence, caused by prolonged pressure or pressure) for one of four sampled residents (Resident 4) when:1. Resident 4 developed a pressure injury on the sacrum (bony structure located at the base of the back), that progressed to osteomyelitis (an infection of the bone).2. Resident 4 developed pressure injuries on left calf, right and left heels from wearing therapeutic moon boots (maintains proper alignment of foot and ankle from turning inward and outward) brought in from his home.This system failure resulted in Resident 4 developing multiple pressure injuries, wound deterioration, subsequent serious… […]

• Actual harm, isolatedF580May 24, 2024

  Based on observation, interview and record review, the facility failed to promptly notify the Medical Director (MD), who was the attending physician, for one of three residents sampled for change of condition (Resident 1), when Resident 1 was experiencing signs and symptoms of stroke (a life-threatening medical emergency, when the blood supply to part of the brain is blocked or reduced) on [DATE], he was transferred to the Acute Hospital on [DATE]. This failure resulted in a three-day delay in transferring Resident 1 to the hospital for treatment, and increased Resident 1's pain and discomfort. Resident 1 suffered significant declines on his functional abilities: slurred speech, left-sided weakness, inability to swallow. […]

• Actual harm, isolatedF689Dec 5, 2023

  Based on interview and record review, the facility failed to ensure the plan of care for a safe transfer was implemented for one of 4 sampled residents (Resident 1) when Certified Nursing Assistant (CNA) l and Nursing Assistant (NA) 2 did not use a Hoyer lift (a mechanical device for lifting and transferring immobile patients) and assisted Resident 1 to a standing position. Resident 1 was unable to stand and was lowered to the floor. This failure resulted in an avoidable fall for Resident 1 and caused fractures to her right knee, pain, and delay in physical therapy treatments. […]

• Actual harm, isolatedF690Mar 23, 2021

  Based on observation, interview, and record review, the facility failed to ensure that residents received appropriate treatment and services to prevent urinary tract infections when 1. staff did not monitor the urinary catheters (a drainage system placed in the bladder to drain urine) for 6 of 6 sampled residents (Residents 1, 3, 5, 7, 9, and 10) as ordered by the physician, and 2. Staff did not practice appropriate hand hygiene when providing pericare (cleaning an incontinent resident after elimination). These failures had the potential to contribute to 3 of 6 sampled residents (Residents 3, 9, and 10) having urinary tract infections, and to Resident 10's hospitalization for urinary tract infection with [CONDITION(S)] (blood poisoning). […]