Autumn Lake Healthcare at Bradford Oaks

In the surveyor’s words

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

• No harm, potential for more than minimal, patternF695Apr 10, 2026

  Based on observation, interviews, and record review, it was determined that the facility failed to provide respiratory care consistent with professional standards for oxygen administration. This was found evident of 6 (Resident #13, #23, #41, #133, #149, #171) out of 7 residents reviewed for respiratory care during the survey.Nasal cannula- a medical device used to provide supplemental oxygen therapy to people who have lower oxygen levels.An oxygen concentrator is a medical device that extracts oxygen from room air by filtering out or separating the nitrogen from the oxygen. The oxygen passes through a filter system and is then stored within the device for delivery based on the flow meter setting. […]

• No harm, potential for more than minimal, patternF921Feb 20, 2025

  Based on observations and staff interview, it was determined that the facility failed to maintain a safe and sanitary environment for residents, visitors, and staff. This was evident for the parking lot and the East hallway during the survey. The findings include: On 2/4/25, at 9:45 AM upon entry to the parking lot area in front of the facility's front doors, there were masks, gloves, and various paper packaging littering the ground. The same observations were made on 2/5/25 at 8:50 AM, 2/5/25 at 3:00 PM, 2/7/25 at 7:00 AM, 2/7/25 at 1:00 PM, 2/10/25 at 8:00 AM, 2/10/25 at 4:10 PM, 2/11/25 at 8:30 AM. On 2/11/25 at 1:00 PM, a pile of nonsterile clear gloves was found in a parking spot, as well as the other trash noted previously. […]

• No harm, potential for more than minimal, isolatedF559Apr 10, 2026

  Based on interviews and record review, it was determined that the facility failed to provide the resident/resident representative with written notification of a new roommate. This was evident for 1(Resident#73) of 1 resident reviewed for roommate changes during the recertification survey.The findings include:During an interview on 04/06/26 at 10:44 AM Resident #73 reported that they were not informed in advance that he/she would receive a new roommate. On 04/08/26 at 7:00 AM a review of the clinical record revealed that Resident #73 received a new roommate on 02/04/26. […]

• No harm, potential for more than minimal, isolatedF583Apr 10, 2026

  Based on observation and staff interview it was determined that the facility failed to ensure the personal privacy of a Resident. This finding was found to be evident in 1 (Resident #72) out of 1 Residents reviewed for urinary catheters. The findings include:Urinary Drainage Bag collects urine from a catheter designed to be kept below bladder level to prevent backflow and infections. Urinary drainage bags hang on the bedframe or wheelchair. At 12:34 PM on 4/6/2026 the surveyor observed Resident #72 in bed with a yellow substance in the urinary drainage bag hanging on the bed frame. […]

• No harm, potential for more than minimal, isolatedF584Apr 10, 2026

  Based on observation and staff interviews it was determined that the facility failed to maintain a safe, comfortable, homelike environment for Residents. This finding was found to be evident in 9 (Resident rooms/bathrooms N34 N39, N40, N42, N46, N50, N34, N62 and S72) out of 9 Resident rooms/bathrooms reviewed, and 1 (North Unit shower room) out of 1 shower rooms reviewed for physical environment during the recertification survey.The findings include: 1.On 4/6/26 at 9:58 AM, during the initial tour of the facility, the surveyor observed in room [ROOM NUMBER]-B that resident #8's wardrobe cabinet door was scraped up, about 4x10 inches to the side and that the 2nd draw from the bottom-up area measuring about 2x8 inches were all scraped off revealing the cream-colored wood inside. […]