Autumn Lake Healthcare at Madison

In the surveyor’s words

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

• Actual harm, isolatedF686Nov 13, 2023

  Based on observations, record review policy and interviews for 2 of 6 residents (Resident #9 and Resident #62) reviewed for pressure ulcers, the facility failed to prevent the development of pressure ulcers and failed to provide the necessary treatment and services for residents with a pressure ulcer. For Resident #9, the facility failed to prevent the development of a pressure ulcer in a dependent resident, failed to ensure timely turning and repositioning and off-loading/floating (removal of pressure from a body part), failed to conduct pressure ulcer risk assessments per the facility policy, and failed to conduct weekly skin assessments. […]

• Actual harm, isolatedF689Jun 13, 2022

  Based on clinical record review, review of facility documentation, and interviews for one of three residents reviewed for accidents, (Resident#1), the facility failed to ensure that the resident was positioned properly prior to repositioning in a customized wheel chair, and failed to ensure that the facility staff assisted a vendor in repositioning a resident for an X-ray, resulting in an injury. The findings include: 1) Resident #1's diagnoses included Congestive Heart Failure, and osteoporosis. […]

• No harm, potential for more than minimal, widespreadF725Nov 13, 2023

  Based on observations, facility documentation, resident council minutes, facility policy, review of facility staffing hours, and interviews, the facility failed to adequately staff Nurse Aides (NA) throughout the facility resulting in resident care needs not being met. The findings include: 1. Resident #21 's diagnoses included dementia, heart disease, and communication deficit. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #21 was moderately cognitively impaired and required supervision with transfers and extensive assistance with dressing and personal hygiene. The Resident Care Plan dated 9/1/22 identified Resident #21 required assistance with Activities of Daily Living. Interventions included providing staff assistance with personal hygiene. […]

• No harm, potential for more than minimal, widespreadF809Nov 13, 2023

  Based on observations, facility policy, facility documentation, and interviews for 2 of 2 resident units, for Resident #'s 28, 51, 61, 278, and 428, who were reviewed for receiving a nourishing snack when mealtimes exceeded 14 hours, the facility failed to provide adequate snacks. The findings include: Intermittent interviews on 10/31/23 between 10:30 AM and 2:00 PM and 11/2/23 between 12:00 PM and 2:00 PM with Resident's #28, 51, 61, 278, and 428 identified that the residents were receiving a small snack in the evening only upon request. […]

• No harm, potential for more than minimal, widespreadF880Nov 13, 2023

  Based on observation, facility documentation, facility policy, and interviews, the facility failed to follow infection control practices on 1 of 2 units to provide a clean environment for Resident #53, and for the Infection Control Program, failed to ensure all required infection control policies and procedures were present in the Infection Control Manuals. The findings include: 1. Resident #53's diagnoses included Alzheimer's disease, cognitive communication deficit, and inflammatory polyarthropathy (arthritis affecting 5 or more joints). The quarterly Minimum Data Set assessment dated [DATE] identified Resident #53 was severely cognitively impaired and required the assistance of 1 staff with bed mobility and transfers. […]