Autumn Lane Health and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Autumn Lane Health and Rehabilitation, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Sep 24, 2023

  Based on observations, staff interviews, and a review of the facility policy titled Skilled Nursing Services, the facility failed to ensure that opened food items were labeled and dated. The facility census was 81, with 79 residents receiving an oral diet. Findings included: A review of the facility policy, Skilled Nursing Services, reviewed 12/30/2022, revealed all items should be covered, sealed, labeled, and dated appropriately. An observation on 9/22/2023 at 8:10 a.m. of the walk-in cooler revealed the following: A baggie containing four eggs was open to air, unlabeled and undated. A baggie containing three eggs was open to the air, unlabeled and undated. […]

• No harm, potential for more than minimal, isolatedF677May 16, 2025

  Based on observations, resident and staff interviews, and record review, the facility failed to provide staff assistance with activities of daily living (ADLs), bathing, and oral hygiene, for one (Resident (R) 78) of two residents reviewed for ADLs out of a sample of 18 residents. This failure had the potential to negatively impact the quality of life for the affected resident. Findings include: Review of R78's Face Sheet located in the Admissions tab of the electronic medical record (EMR) revealed R78 was admitted on [DATE] with diagnoses including intracerebral hemorrhage, hemiplegia, muscle weakness, and dysphagia. […]

• No harm, potential for more than minimal, isolatedF759May 16, 2025

  Based on observation, staff interview, record review, and review of the facility policy titled Medication Administration-General, the facility failed to ensure a medication error rate below five percent. During medication administration for two residents (R) (R45 and R77), the correct dosage of medication was not administered to the residents. These failures caused two medication errors out of 25 opportunities for error, or a medication error rate of eight percent. These failures had the potential to increase or decrease the effectiveness of these medications. Findings include: Review of the facility's undated policy titled Medication Administration-General, revealed Medications are administered in accordance with a valid prescriber order. […]

• No harm, potential for more than minimal, isolatedF880May 16, 2025

  Based on observations, interviews, record review, and review of the facility policies titled Wound Care and Hand Hygiene, the facility failed to adhere to infection control practices and policies during wound care related to staff failing to perform hand hygiene during glove changes and placing supplies on resident's dirty bedside table for two of two residents (Resident (R) 81 and R29) observed for wound care in the sample of 22 residents. The deficient practice increased the risk of cross-contamination and infections. Findings include: Review of the facility's undated policy titled Wound Care, provided by the facility indicated, Remove gloves and perform hand hygiene. Put on second clean gloves. […]

• No harm, potential for more than minimal, isolatedF641Sep 24, 2023

  Based on record review, staff interviews, and a review of facility policy titled MDS compliance, the facility failed to ensure three of 25 sampled residents (R) (36, 48, and 62). Minimum Data Set assessments were accurate. Findings include: Review of facility policy titled MDS Compliance last reviewed 12/30/2022 revealed 'Each resident's assessment will be coordinated by and certified as complete by a registered nurse, and all individuals who complete a portion of the assessment will sign and certify to the accuracy of the portion of the assessment he or she completed.' 1. Record review of the Physician orders for R36 revealed an order for Indwelling urinary catheter to bedside drainage dated 11/11/2022. […]