Autumn Lake Healthcare at Riverview

In the surveyor’s words

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

• Actual harm, isolatedF689May 19, 2021

  Based on medical record review, administrative report reviews, facility staff, and family interviews, it was determined that the facility failed to provide residents (Resident #4 and #6) with adequate supervision and a safe environment. This resulted in harm to one resident (Resident #4) when the unattended resident fell out of a shower chair and sustained a left [CONDITION(S)] that required hospitalization . A second resident (Resident #6) with cognitive impairment was left in an unsafe environment by leaving a bed without a mattress in the resident room. This resulted in skin tears from the exposed bed-springs. This was evident for 2 of 3 residents reviewed for safe environment during the complaint survey. The findings include: 1. […]

• No harm, potential for more than minimal, patternF584Jun 12, 2026

  Based on interviews, observations and record reviews, it was determined that the facility failed to provide adequate linen for residents. This was evident for two ([NAME] and Swan) out of four units observed during the recertification survey.The findings include:On 06/08/2026 at 8:26 AM, an interview with Resident #253 was conducted. They reported that the facility staff did not have enough linen and there were not enough bed sheets. The resident alleged that they were put in wheelchairs in the morning due to lack of bed sheets to make clean beds. On 06/08/2026 at 1:26 PM, an interview with Resident #128 was conducted. They reported that there were no sheets to make their bed and that the facility had a shortage of linen. […]

• No harm, potential for more than minimal, patternF880Jun 12, 2026

  Based on record review, observation and interview, it was determined that the facility failed to maintain infection prevention and control regarding enhanced barrier precautions while providing high contact care. This was evident for four (Resident #12, #24, #147 & #223) out of seven residents reviewed for respiratory care. The findings include: Enhanced Barrier Precautions (EBP) are infection control measures, primarily for nursing homes, requiring healthcare workers to wear gloves and gowns during high-contact resident care activities (like bathing, dressing) to prevent spreading multidrug-resistant organisms (MDROs) to hands and clothing, even if blood/body fluid exposure isn't expected, extending standard precautions for residents with multidrug-resistant organisms (MDROs) or at high… […]

• No harm, potential for more than minimal, patternF641Apr 30, 2026

  Based on medical record review and staff interview, it was determined the facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded. This was evident for 6 (Residents #3, #1, #9, #4, #12, #10) of 16 residents reviewed during a complaint survey.The findings include: The MDS is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on those individualized needs, and that the care is provided as planned to meet the needs of each resident. […]

• No harm, potential for more than minimal, patternF684Jun 3, 2025

  Based on interview and record review, the facility failed to timely administer medications as ordered. This was evident for 1 (Resident #86) of 85 residents reviewed for medications administration involving 22 medications administered during 6 days in May 2025. The findings include: On 5/27/25 at 11:52 AM, during an interview conducted with Resident #86, the resident expressed the concern that his/her medications are not given on time, especially the medication for his/her liver. On 5/29/2025 at 8:30 AM, a review of Resident #86's MAR for 2025 in the electronic medical record revealed documentation of a check mark for all medications, which indicated that they had been administered. […]