Autumn Lake Healthcare at Alice Manor

In the surveyor’s words

From the most serious findings on record at Autumn Lake Healthcare at Alice Manor, in the surveyor’s own words.

• Actual harm, isolatedF760Nov 20, 2024

  Based on medical record review, review of pertinent facility documentation, hospital record review and staff interview, it was determined the facility failed to ensure that residents were free from significant med errors as evidenced by a resident being administered medication that was not prescribed resulting in the resident ' s hospitalization . This was evident for 1 (#16) of 3 residents reviewed for medication administration during a complaint survey. This failure resulted in actual harm to Resident #16. The facility implemented effective and thorough corrective measures following this incident and prior to the start of this survey. […]

• No harm, potential for more than minimal, widespreadF756Jun 14, 2021

  Based on review of medical records and interview with staff, it was determined that the facility failed to have an effective system in place to 1) ensure that drug regimen reviews were done for all residents at least monthly, 2) ensure tht pharmacist recommendations were acted upon timely from identified irregularities during the monthly pharmacy review and 3) have evidence that drug regimen reviews were completed, addressed and acted on by the physician. This was evident for 4 (#32, #31, #54, #9) out of the 5 residents reviewed for medication regimen review during the annual survey but affected all residents in the facility. The findings include: 1) A record review was conducted for Resident #32 on 6/7/21 at 12:33 PM. […]

• No harm, potential for more than minimal, patternF657Apr 17, 2026

  Based on medical record reviews and staff interviews, it was determined that the facility failed to ensure that 1) residents were offered the opportunity to participate in the care planning process, 2) Interdisciplinary Team (IDT) care plan meetings were conducted. This was evident for 4 (Residents #13, #40, #35, and #2) of 28 residents reviewed for care planning during the recertification/complaint survey.The findings include:Care plans are essential guides for the care residents receive. Regulations require that care plans be developed within seven days of a resident's comprehensive admission Minimum Data Set (MDS) assessment and be revised at least quarterly, or more frequently if a change in condition occurs. […]

• No harm, potential for more than minimal, patternF727Apr 17, 2026

  Based on record reviews and interview, it was determined that the facility failed to ensure a registered nurse (RN) was on duty for at least 8 consecutive hours, 7 days a week. This was evident for 12 of 30 days reviewed during the recertification survey. The findings include: On 4/17/2026 at 7:17 AM, a review of the facility's staffing sheets revealed that no RN was on duty for at least 8 consecutive hours in a 24-hour period on the following dates: 1/3/26, 1/4/26, 1/10/26, 1/11/26, 1/17/26, 1/24/26, 1/25/26, 1/31/26, 2/7/26, 2/8/26, 3/8/26, and 4/5/26. On 4/17/2026 at 8:06 AM, the Director of Nursing (DON) verified the findings and acknowledged the concern.

• No harm, potential for more than minimal, patternF761Apr 17, 2026

  Based on observation and interview it was determined the facility failed to properly label and store drugs and biologicals. This was evident in 4 of 4 medication carts and 2 of 2 medication rooms observed during the recertification/complaint survey. The findings include: On 04/15/2026 at 9:06 AM, observation of medication cart one on the 2nd floor accompanied by Staff #11 Med Tech revealed the following:An over-the-counter medication bottle of Ger-Kot 8.6 mg tablets with an expiration date of 10/2025; this was verified by Staff #11, who voiced during the observation that the medication should have not been in the medication cart as it has expired.On 04/15/2026 at 9:16 AM, during an observation of the 2nd floor short hall medication cart accompanied by Staff #10 Agency Licensed Practical… […]