Autumn Lake Healthcare at Braddock Heights

In the surveyor’s words

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

• No harm, potential for more than minimal, patternF600Aug 16, 2024

  Based on record review, staff interviews, and facility policy review, the facility failed to ensure four of six residents reviewed for abuse (Residents (R) 22, R11, R106 and R35) out of a total sample 29 were free from resident-to-resident abuse. This failure had the potential to cause physical injury or psychosocial distress for the four residents involved. Findings include: Review of the facility's policy titled Abuse, Neglect and Exploitation dated 11/13/23 indicated, .It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property .'Abuse' means the willful inflection of injury,… […]

• No harm, potential for more than minimal, patternF880Aug 16, 2024

  Based on policy review, interviews, and review of Centers for Disease Control (CDC) and American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE) guidelines, the facility's water management program was incomplete in that it was not consistent with current ASHRAE guideline, which specifically called for the design to evaluate the potential exposure of Legionnaire's disease (a serious pneumonia infection) within a healthcare facility. This failure created a potential for the 43 facility residents, who were over the age of 65, to be infected by Legionella Findings include: Review of the CDC website titled Legionella. Prevention and Control, dated 03/25/21, indicated, The key to preventing Legionnaires' disease is to reduce the risk of Legionella growth and spread. […]

• No harm, potential for more than minimal, patternF641Mar 1, 2021

  Based on medical record review and staff interview, it was determined the facility staff failed to ensure that Minimum Data Set (MDS) assessments were accurately coded. This was evident for 3 (Resident #7, #5, #17) of 6 residents reviewed for facility reported incidents during a complaint survey. The findings include: The MDS is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on those individualized needs, and that the care is provided as planned to meet the needs of each resident. […]

• No harm, potential for more than minimal, patternF880Mar 1, 2021

  Based on documentation review, interview and observation, it was determined that the facility failed to have an effective system in place to prevent further transmission of disease by 1) failing to ensure that newly admitted residents with an undetermined COVID-19 status, were admitted to a single person room, 2) failing to follow infection control guidelines during the laundry process and 3) failing to ensure that staff utilized personal protective equipment (PPE) in a manner that met minimum standards and minimized risk for infectious spread. The noncompliant practices within the facility infection prevention and control program left all residents, staff, and visitors at increased risk for harm during a declared health pandemic. […]

• No harm, potential for more than minimal, isolatedF558Jan 23, 2026

  Based on observation and interview, it was determined that the facility failed to ensure residents' call devices were in reach. This was evident for 1 resident (Resident #39) of 24 residents screened during the initial pool portion of the recertification survey.The findings include:Resident #39 was admitted to the facility for care due to a degenerative neurological condition which caused them to be dependent on others for personal care. On 1/14/26 at 8:53 AM an observation and interview was conducted in Resident #39's room as part of the initial tour and screening during the recertification survey. The resident was seated upright in bed. They were awake, alert and easily engaged in conversation. The resident said that they were unable to reposition themselves without assistance. […]