Autumn Lake Healthcare at Cherry Lane

In the surveyor’s words

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

• No harm, potential for more than minimal, patternF584Aug 4, 2023

  Based on surveyor observation and staff interview it was determined the facility staff failed to keep the building clean, neat, attractive and in good repair. This was evident on both floors of the facility. The findings include. An environmental tour was conducted with the maintenance director (staff #16) on 7/21/23 at 9 AM. The maintenance director was informed of the accumulated environmental concerns by multiple members of the survey team during the initial days of the survey beginning on 7/10/23. […]

• No harm, potential for more than minimal, patternF610Aug 4, 2023

  Based on interviews and record review it was determined the facility failed to perform a thorough investigation of an allegation of abuse. This was evident for 4 (Resident #253, #1, #175, and #71) out of 6 residents reviewed for abuse. The findings include: 1) Resident #253 relayed to the surveyor on 7/11/23 at 12:02 PM an allegation of abuse in which they had reported that an Occupational Therapist was swinging the cane at me (approximately) last Thursday (7/6/23) and the facility reported to my family that I was threatening the staff. On 7/17/23 at 12:01 PM, PTA (Staff #28), stated in an interview with surveyors regarding the alleged incident on 7/7/23: We had to pull him/her back in the chair. We snugged him/her back in the chair by the gait belt. […]

• No harm, potential for more than minimal, patternF622Aug 4, 2023

  Based on a review of a complaint intake, medical record review, and staff interview it was determined that the facility failed to document the reason leading up to a transfer of a resident to the hospital in the medical record including a reason for the transfer. This was evident for 1 (Resident #160) of 6 residents reviewed for hospitalization . The findings include: On 7/25/23 complaint intake, MD00140476 was reviewed related to resident #160. Based on a review of the complaint the resident had a fall, and busted his/her head and was transported to the emergency room . A review of resident #160's closed medical record on 7/25/23 did not reveal any evaluations or progress notes indicating the resident had a fall and was transferred to the hospital. […]

• No harm, potential for more than minimal, patternF623Aug 4, 2023

  Based on medical record review and staff interview it was determined the facility staff failed to notify the resident/resident representative in writing of a transfer/discharge of a resident along with the reason for the transfer. This was evident for 4 (Residents #105, 119, 106, and 160) of 6 residents reviewed for Notice requirements before transfer/discharge. The findings include: 1) Review of the medical record for Resident #105 on 7/28/2023 at 10:07 AM revealed that Resident #105 was transferred to an acute care facility on the following dates: 2/8/2022 for left hip acute fracture, on 10/29/2022 for change in mental status, on 4/12/2023 for unwitnessed fall, and on 7/13/2023 for change in mental status and hypotension (low blood pressure). […]

• No harm, potential for more than minimal, patternF656Aug 4, 2023

  Based on record review and interviews, it was determined that the facility failed to failed to develop and implement comprehensive, Resident-centered care plans for residents residing in the facility. This was evident for 5 (Resident #71, #252, #177, #93, and #399) of 33 resident care plans reviewed during the survey. The findings include: 1) A review of Resident #71's physicians orders on 7/18/23 at 1:51 PM revealed an order dated 6/23/23 for OT (Occupational Therapy) Clarification; RNP (Registered Nurse Practitioner) order; Resting hand splint to be worn on L [left] hand 8hrs [hours] on, during the day, assessing for redness, skin tears, and maintaining palmar hygiene and nail hygiene. […]