Autumn Lake Healthcare at Birch Manor

In the surveyor’s words

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

• Actual harm, isolatedF578Mar 4, 2021

  Based on record review and staff interview, it was determined that the facility staff failed to accurately interpret a Medical Orders for Life-Sustaining Treatment (MOLST) form and provided Cardiopulmonary Resuscitation (CPR) to a resident deemed by 2 physicians to be medically unnecessary. The resident was subjected to unnecessary CPR at the end of his/her life that resulted in harm to the resident. This was evident for 1 of 4 residents (Resident #14) reviewed for MOLST accuracy at time of death. Due to the facility's corrective measures following the incident, this is being cited as past non-compliance with a compliance date of [DATE]. […]

• No harm, potential for more than minimal, widespreadF657Jun 11, 2025

  2) Review of Resident #59's medical record on 6/6/25, revealed the resident has resided at the facility for several years and had a MDS assessment with an assessment reference date (ARD) of 3/25/25. Further review of the medical record failed to reveal documentation to indicate a care plan meeting had occurred following the March MDS assessment. On 6/6/25 at 3:23 PM an interview with Staff #26 revealed she is sent the MDS dates and her process was to write down every name she sees and then calls the family to schedule a meeting. If she gets a call back then she schedules a meeting. When asked what happens if no call back, Staff #26 stated : usually have a meeting with the unit manager. She went on to indicate she would invite the resident, if deemed capable, and the family. […]

• No harm, potential for more than minimal, patternF565Jun 11, 2025

  Based on review of resident council meeting notes and interviews it was determined that the facility failed to have an effective system in place to ensure grievance/concerns expressed during Resident Council were addressed and followed up on. This was found to be evident for three out of the past seven months of resident council meeting minutes reviewed. The findings include: On 6/5/25 review of the Resident Council Minutes for the meetings held from October 2024 through May 2025 revealed they were a typed word document that does not include specific sections to address follow up of old business. […]

• No harm, potential for more than minimal, patternF656Jun 11, 2025

  4. On 6/5/25 at 9:36 AM Resident #76 was observed in bed, the resident replied to surveyor greeting with a thumbs up but did not verbally respond. Review of Resident #76's medical record revealed the resident had resided at the facility for more than a year and was totally dependent on staff for activities of daily living such as dressing, eating, transferring from bed to wheelchair and mobility. According to the resident's care plan, the resident had a communication problem related to expressive aphasia (unable to communicate verbally) but was able to communicate by pointing and gestures. […]

• No harm, potential for more than minimal, patternF679Jun 11, 2025

  3) On 6/5/25 at 9:36 AM Resident #76 was observed in bed, the resident replied to surveyor greeting with a thumbs up but did not verbally respond. Review of Resident #76's medical record revealed the resident had resided at the facility for more than a year and was totally dependent on staff for activities of daily living such as dressing, eating, transferring from bed to wheelchair and mobility. According to the resident's care plan, the resident had a communication problem related to expressive aphasia (unable to communicate verbally) but was able to communicate by pointing and gestures. On 6/9/25 review of the annual MDS assessment, dated 2/10/25, revealed an interview was conducted with the family, or significant other, for Section F Activities. […]