Autumn Lake Healthcare Post-Acute Care Center

In the surveyor’s words

From the most serious findings on record at Autumn Lake Healthcare Post-Acute Care Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Mar 21, 2023

  Based on medical record review, administrative record review, and staff interviews, it was determined that the facility failed to protect a cognitively impaired resident (Resident #362) from physical abuse from a facility staff member on 5/15/22. This was evident for 1 of 29 residents (Resident #362) reviewed for abuse during an annual recertification survey. Resident #362 sustained a fall during a physically abusive incident and suffered a fractured hip. Thereafter, Resident #362 never regained his/her ability to walk independently. This failure to protect residents from physical abuse by facility staff members resulted in an Immediate Jeopardy. […]

• No harm, potential for more than minimal, widespreadF684Mar 21, 2023

  Based on observation, medical record review, and interview with staff it was determined that the facility failed to ensure residents received treatment and care in accordance with professional standards of practice as evidenced by 1.) failure to follow physician orders for 1 of 8 (Resident #155) residents reviewed for pressure ulcers, and 2 of 10 (Resident #40 and #19) residents reviewed for physician orders; 2.) failure of the GNA to notify the nurse after a resident had a fall for 1 of 5 (Resident # 609) residents reviewed for falls; 3.) failure of the facility to ensure that a resident received treatment for a possible wound infection for Resident #359, and 4.) failure to administer a pain medication for Resident #87 as ordered by the physician. […]

• No harm, potential for more than minimal, widespreadF812Mar 21, 2023

  Based on observation, record review, and staff interview it was determined that the facility staff failed to store, prepare, and serve food and beverages using proper sanitary practices. This deficient practice has the potential to affect all residents in the facility. Findings include: An initial tour of the facility's kitchen was conducted on [DATE] at 08:15 am with the Dietary Manager (DM) #27 present. After surveyors sanitized hands and donned hairnets. Dietary Aid (DA) #34 entered the kitchen, passed surveyors and DM #27, opened, and entered a storage refrigerator without sanitizing their hands. The DM #27 was alerted to the observation and asked what was the expectation of staff entering into the kitchen. […]

• No harm, potential for more than minimal, patternF658Nov 24, 2025

  Based on record reviews and staff interviews, it was determined that the facility failed to adhere to professional standards of quality of care based on established clinical practices, physician orders, or facility policies regarding enteral feeding and medication administration. This was evident for 4 residents (Residents #9, #210, #208 and #117) out of 4 residents reviewed for professional standards of quality care during the survey. Findings include:Professional standards of quality relate to the requirement that services provided in a long-term care facility must heavily involve proper medication administration practices. […]

• No harm, potential for more than minimal, patternF921Nov 24, 2025

  Based on observations, interviews with staff and residents' families, and review of Complaints, it was determined that the facility failed to 1.) ensure a safe, functional, sanitary, and comfortable environment for residents, staff, and the public; 2.) provide enough clean linen to all residents; and 3.) ensure repairs were made to a resident door and the hallways hand railings. This was evident for 5 (333137, 333135, 333139, 333141 and 333113) out of 5 complaint intakes; 2 (residents #11 and #140) out of 2 residents; and the hallway railing on the third-floor dementia unit observed for sanitary conditions during the survey. The findings include:1. On 11/20/2025 at 10:07 AM, the surveyor reviewed complaint #333113 which alleged that the facility did not have enough linen for all residents. […]