Autumn Lake Healthcare at Overlea

In the surveyor’s words

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

• Actual harm, isolatedF686Apr 13, 2026

  Based on complaint, reviews of all pertinent documents and a closed medical record, and interviews with facility staff, it was determined that the facility failed to implement preventative measures to prevent the development and deterioration of a resident's pressure ulcers. This was evident for 1 (Resident #2) out of 4 residents reviewed during a survey. The findings include: On 03/30/26 the Office of Health Care Quality received a complaint with concerns that Resident #2 was not provided with quality of care. […]

• No harm, potential for more than minimal, widespreadF567Apr 30, 2025

  Based on record review and interview it was determined that the facility staff failed to ensure residents whose funds were managed by the facility had access to their money anytime. This deficient practice was evidenced in 94 of 94 resident accounts being managed by the facility staff. The findings include: On 04/28/25 at 11:28 AM during an interview with Business Office Manager # 31 the surveyor asked a series of questions related to the residents' ability to access their finances. Business Officer Manager #31 verbalized the normal business hours at the facility was 8:30 AM-5:00 PM Monday-Friday and he/she is available on Friday if any of the residents need money for the weekend. Prior to the Coronavirus Disease 2019 (COVID-19) pandemic the Receptionist would give the residents money. […]

• No harm, potential for more than minimal, widespreadF812Apr 30, 2025

  Based on observation, record review and interviews it was determined that the facility staff failed to ensure the high temperature dishwasher's final rinse was at the temperature to sanitize the dishes and utensils at the required 180F-Fahrenheit degree temperature,and 2) failed to ensure that the foods are stored, prepared, distributed, and served in accordance with professional standards for food service safety procedures. This was evident for 11 of 11 food service and kitchen equipment in the kitchen areas noted during survey activities. The findings include: 1) On 04/23/25 at 10:15 AM, an initial tour of the kitchen area was conducted with the District Manager and the Dietary Manager. […]

• No harm, potential for more than minimal, widespreadF880Apr 30, 2025

  Based on observations and interviews it was determined that the facility staff: 1) failed to label residents basins and urinals to prevent cross contamination of bodily fluids in shared bathrooms located on the second floor and 2) failed to ensure that the clean linens were kept separate from the contaminated linen by the use of separate rooms, closets, or other designated spaces with a closing door to provide secure methods for reducing the risk of accidental contamination within the laundry rooms. This was observed during an annual survey. The findings include: 1) During observation rounds on 04/24/25 at 8:26 AM the surveyor observed two round and 1 square unlabeled basin in the shared bathroom between Rooms 205-207 located on the second floor. […]

• No harm, potential for more than minimal, patternF921Jul 6, 2026

  Based on observation and staff interviews, it was determined that the facility failed to maintain a safe and functional environment for residents, staff and visitors. This deficient practice was evident for 3 (Residents #63, #74, and #76) out of 32 residents reviewed for the physical environment and during a observation of the resident's smoking area conducted during the annual survey.The findings include: 1) At 1:30 PM on 6/30/2026 the surveyor observed the blinds opened to the three (3) windows in Resident room G-5. In the middle window looking out to the facility's parking lot was a large crack that extended from the top right-hand corner of the window which curved diagonally to the left-hand side towards the bottom 1/3 of the window. […]