Autumn Lake Healthcare at Ballenger Creek

In the surveyor’s words

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

• Immediate jeopardy, isolatedF760Nov 15, 2022

  Based on medical and administrative record review and staff interview, it was determined that the facility failed to ensure that residents were free from significant medication errors as evidenced by a resident being administered medications that were ordered for their roommate. These findings were evident for 1 (Resident #263) of 6 residents reviewed for complaints during the annual survey. This was identified during the investigation of # MD000178787. The facility provided evidence that an action plan was developed, and corrective measures were implemented on 6/11/22, immediately after the facility was made aware of the incident to remove the immediacy of the noncompliance and correct the deficient practice.On 11/10/22 a determination of immediate jeopardy (IJ) was made with the… […]

• Actual harm, isolatedF689Nov 15, 2022

  Based on review of medical records and other pertinent documentation, observations, and interviews, it was determined that the facility failed to ensure adequate supervision to prevent falls as evidenced by: 1) Failure of the geriatric nursing assistant (GNA) to remain with a resident who, due to a stroke and resulting muscle weakness and cognitive impairment, required total assistance with bathing during a shower. The resident sustained an unwitnessed fall during the shower. This fall resulted in a leg fracture, transfer to the hospital and subsequent surgical repair. 2) Failure of the GNA to provide supervision to a resident with severe dementia, who required extensive assistance with mobility, after assisting the resident to the toilet. […]

• No harm, potential for more than minimal, widespreadF812Jun 30, 2025

  Based on observations, interviews, and record review, it was determined that the facility failed to store and prepare food in accordance with professional standards. This deficient practice has the potential to affect all residents. The findings include: 1) An observation of the facility's walk-in refrigerator on 6/23/25 at 7:08 AM, with staff #48, Interim dietary services manager present, showed 9 cartons of milk with expiration dates of 6/22/25. A continued observation of the walk-in freezer showed 10 bags of veal meat in a paper box. Staff stated the meat was received on 10/9/24; however, there was no label of the expiration date. […]

• No harm, potential for more than minimal, widespreadF887Jun 30, 2025

  Based on employee file reviews and staff interviews, it was determined that the facility failed to ensure that staff were offered and educated about COVID-19 immunizations. This was evident in five (Staff #14, #25, #26, #27, #28) out of six employee files reviewed for staff immunization compliance. The findings include: On 6/26/25 at 4:19 PM, the surveyor reviewed six employee records and was unable to find evidence that education or an offer of the most recent 2024-2025 COVID-19 vaccine had been provided for five out of the six reviewed. On 6/27/25 at 11:54 AM, the surveyor spoke with the facility's Infection Preventionist to inquire about evidence of staff education and documentation indicating that the 2024-2025 COVID-19 immunization had been offered. […]

• No harm, potential for more than minimal, widespreadF607Nov 15, 2022

  Based on record review and staff interview, it was determined that the facility failed to develop and implement abuse policies and procedures. This was evident for 1 of 1 abuse policy reviewed and 1 self- reported incident (MD00164226) of 34 self-reports of abuse allegations. The findings include: A review of the facility's Abuse, Neglect, and Exploitation policy, dated 8/1/21, v was conducted. In section III: Prevention of Abuse, Neglect, and Exploitation, reads, The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves:. […]