Autumn Lake Healthcare at Oak Manor

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Jul 1, 2025

  Based on administrative and medical record review, observations and interviews with facility staff and family it was determined that the facility failed to prevent a cognitively impaired resident who is at risk for wandering from exiting the facility unsupervised. This was evident for 1 (Resident #1) of 4 residents reviewed during the facility's complaint survey. This failure resulted in an Immediate Jeopardy for Resident #1. The facility implemented effective and thorough corrective measures following this incident. The facility's plan and action were verified during this survey; therefore, this deficiency will be cited as past noncompliance. […]

• Actual harm, isolatedF684Apr 1, 2021

  Based on surveyor review of clinical records, the review of administrative records, and interviews with staff, it was determined that the facility staff failed to ensure appropriate pain management and timely treatment was provided in accordance with professional standards for 1 of 3 residents reviewed during the complaint survey (Resident #1). The facility's failure to report a fracture to the attending physician and administer medication according to the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This finding of actual harm was identified during the investigation of complaints MD 661, MD 741, and facility reported incident MD 666. […]

• No harm, potential for more than minimal, patternF569Apr 7, 2026

  Based on record review and interview, it was determined the facility failed to notify residents receiving Medicaid benefits to spend down when their personal account reached within $200 of the SSI resource limit. It was evident for 8 residents (Resident #12, Resident #48, Resident #54, Resident #57, Resident #62, Resident #104, Resident #108, Resident #129) out of 73 residents reviewed for personal funds. The findings include: On 4/6/26 at 11 AM, a review of the facility's [fund management company] report dated 4/3/26 revealed 8 residents with personal accounts that exceed $2500, which is the SSI resource limit. Per this report:1). Resident #12 had $2625.53 in his/her personal fund account.2). Resident #48 had $3235.99 in his/her personal fund account.3). […]

• No harm, potential for more than minimal, patternF641Apr 7, 2026

  Based on record review and staff interview, it was determined that the facility failed to code the residents' status accurately on the Minimum Data Set (MDS) assessment. This was evident for 4 ( Resident #2, Resident #31 Resident #98 and Resident #129) of 6 residents reviewed for accuracy of assessments. The findings include: The Minimum Data Set (MDS) is a federally mandated comprehensive, standardized clinical assessment tool of all residents in nursing home. Staff members gather information on each resident's strengths and needs. Information collected drives resident care planning decisions. MDS assessments need to be accurate to ensure each resident receives the care that they need. 1.) On 03/30/2026 at 11:44 AM, the surveyor observed Resident #2. […]

• No harm, potential for more than minimal, patternF887Apr 7, 2026

  Based on record reviews and interviews, it was determined that the facility failed to educate and provide COVID-19 immunizations to the residents. This was evident for 5 (Resident #28, #57, #48, #39, #12) out of 5 residents reviewed for immunizations during the recertification survey. The findings include: On 04/06/2026 at 2:20 PM, the surveyor requested the facility to provide COVID-19 policy and proof that Resident #28, #57, #48, #39 and #12 had been educated and offered COVID 19 vaccine in 2025. On 04/06/2026 at 2:30 PM, a review of records was conducted. Review of residents' electronic records indicated that Resident #28, #12, #48 and #57 had received COVID-19 immunizations on 11/11/2024. Resident #39 was last offered COVID-19 immunization in 2023. […]