Autumn Lake Healthcare at Oakview

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF801Nov 3, 2023

  Based on interview of facility staff, it was determined the facility failed to ensure that a full-time qualified dietetic service supervisor for oversight of food preparation and daily kitchen operation and a certified Registered Dietician for nutrition management. This has the potential to affect all residents. The findings include: On 10/19/23 at 10:21 AM, an interview with the Kitchen Manager staff #51 revealed that he was not clinically qualified as per Federal and state regulations. During the interview, he reported that he had been in his position for two and a half years. He reported that he had completed his coursework, but had not yet passed the Certified Dietary Manager (CDM) exam. He stated he planned to take the exam in November 2023. […]

• No harm, potential for more than minimal, widespreadF803Nov 3, 2023

  Based on review of pertinent documentation, observation, and interviews with resident and staff, it was determined that the facility failed to ensure that residents were served meals according to a predetermined menu that incorporated resident preferences. This was evident for 5 (Resident # 112, Resident # 49, Resident # 25, Resident #2, Resident #59) out of 6 residents on 5 of the 6 units at the facility reviewed for food during a survey. This has the potential to affect all residents. The findings include: 1. Resident #112 was admitted to the facility for rehabilitation and wound care. An observation of resident's menu ticket and tray was made on 10/16/23 at 12:16 PM. […]

• No harm, potential for more than minimal, patternF658Aug 3, 2026

  Based on observation, record review, policy review, and interview, it was determined that the facility failed to follow professional standards of nursing practice for medication administration and for timely, accurate clinical documentation. This was evident for 3 residents (Resident #20, Resident #6, and Resident 140) of 38 residents reviewed during the survey investigation and medication administration facility task.The findings include: 1) On 07/29/2026 at 11:02 AM a reviewing the Resident #140 electronic health record (EHR) revealed the resident was sent to the hospital for further medical evaluation on the morning of 02/15/26. Licensed Practical Nurse (LPN) #45 documented details of the incident on 02/15/36 at 7:09 PM and documented the time as 8:09 AM. […]

• No harm, potential for more than minimal, patternF641Aug 5, 2025

  Based on record review and staff interview, it was determined the facility failed to accurately code the residents' status in the Minimum Data Set Assessment. This was evident for 4 (Resident #138, Resident #1, Resident #4 and Resident #10) out of 8 residents reviewed for Accuracy of Assessments.The findings include: Aripiprazole (often sold under the brand name Abilify) is an atypical or second-generation antipsychotic medication. It's used to treat various mental health conditions such as Bipolar. Fluoxetine hydrochloride is a widely used antidepressant medication, commonly known by its brand name Prozac. It is commonly used to treat depression. […]

• No harm, potential for more than minimal, patternF812Aug 5, 2025

  Based on observations, facility documentation, and staff interviews, it was determined that the facility failed to maintain refrigerated food temperatures at a safe level. This was found to be evident for the 3rd floor nourishment room refrigerator during the annual survey.The findings include:PHF (Potentially Hazardous Food) and TCS (Time/Temperature Control for Safety) foods are foods that require specific time and temperature controls to limit the growth of harmful microorganisms. According to the Food and Drug Administration recommendations and regulations, TCS/PHF foods must be stored at 41 F or below.The 3rd floor nourishment room refrigerator was observed by the survey team on 7/24/2025 at 10:24 AM. […]