Autumn Lake Healthcare at Arlington West

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF812May 6, 2022

  Based on observation, interview, and documentation review it was determined that the facility staff failed to store, prepare, and maintain a sanitary environment in accordance with professional standards for food service safety by failing to ensure dishwasher hot water temperatures are frequently checked to ensure cleanliness and sanitation of dishware, failing to ensure safe refrigerator temperatures and failing to dispose of outdated food items. This practice had the potential to affect all residents that consumed food that was prepared by the kitchen. The findings include: 1) An initial environmental kitchen food services inspection was conducted on 4/19/22 at 8:46 AM. The dishwasher temperature log was found near the dishwasher hanging on a clipboard. […]

• No harm, potential for more than minimal, patternF550May 6, 2022

  Based on observation and staff interview, it was determined that the facility staff failed to provide residents with dignity and respect by improperly transporting residents down the hall (Resident #70, Resident #173 Resident #21 and assisting a resident to eat (Resident #65). These events were evident during 5 random observations on the facility nursing units during the survey. The findings include: 1) During an observation of the 3rd-floor nursing unit on 04/20/2022 at 11:11 AM, therapy staff member #14 was observed pulling Resident #70 backwards in a wheelchair down the hallway towards the main dining area. […]

• No harm, potential for more than minimal, patternF610May 6, 2022

  Based on interview and review of facility reported incident (FRI) investigation documentation it was determined the facility staff failed to thoroughly investigate incidents of alleged verbal and physical abuse. This was evident for 5 of 6 residents (Resident #9, #225, #226, #275, #276) reviewed for abuse. The findings include: 1) On 4/28/2022 at 2:00 PM, review of the facility reported incident MD 599 revealed that Resident #9 had alleged that GNA #33 slapped him/her. The facility administrative staff investigated and substantiated the allegation of physical abuse and terminated GNA #33. Resident #9's roommate was noted as not a reliable witness and was not interviewed. […]

• No harm, potential for more than minimal, patternF656May 6, 2022

  Based on record reviews, observation, and staff interview, it was determined that the facility failed to: 1) develop and implement comprehensive person-centered care that were resident specific with measurable objectives and goals (Resident #26, #66, #57, #273) and 2) develop a care plan to address the use of an anticoagulant (Resident#58). This was evident for 5 out of 55 residents reviewed during an annual recertification survey. The findings include: A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess and evaluate the effectiveness of the resident's care. The MDS is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. […]

• No harm, potential for more than minimal, patternF688May 6, 2022

  Based on observation, medical record review and staff interview it was determined the facility failed to have a process to ensure that residents with a limited range of motion received the appropriate treatment and services to prevent further decline in range of motion. This was evident for 3 of 4 residents (Resident #21, #26, #66) reviewed for limited range of motion during the survey. The findings include. 1) Resident #21's medical record was reviewed on 4/20/22 at 1:15 PM. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . […]