Autumn Leaves Nursing and Rehab Inc

In the surveyor’s words

From the most serious findings on record at Autumn Leaves Nursing and Rehab Inc, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jun 24, 2025

  Based on observation, interview, and record review, the facility failed to ensure the residents' environment remained free from accident hazards and the residents received adequate supervision and assistance to prevent accidents for 1 of 5 residents (Resident #1) reviewed for accidents. The facility failed to provide Resident #1 with adequate supervision and assistance on 3/25/25 when a mechanical lift (specialized device designed to safely transfer individuals with limited mobility) sling broke while CNA A was conducting a mechanical lift transfer without the required two (2) staff members, causing Resident #1 to fall from the mechanical lift sling and sustain a minor injury, a hematoma (collection of blood) on the back of her head. […]

• Actual harm, isolatedF689Jun 12, 2023

  Based on interview, and record review, the facility transportation staff failed to ensure resident received adequate supervision and assistance devices to prevent accident for 1 (Resident #1) of 1 resident reviewed for accidents. The facility failed to secure Resident #1 in wheelchair while being transported in the facility van from dialysis. This failure could place residents in the facility who required assistive safety devices when traveling in the facility van at risk for accidents. […]

• No harm, potential for more than minimal, widespreadF755May 7, 2026

  Based on interview and record review, the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation for the facility's only discontinued narcotic drug storage reviewed for reconciliation. The facility failed to ensure they had a log of the discontinued narcotic drug storage on 05/05/26. This failure could place residents at risk for missing medications and medication errors.Findings included: During an observation and interview on 05/05/26 at 01:55PM, the Acting DON took this surveyor to observe the discontinued narcotic drug storage. She unlocked the door and opened it, then unlocked the cabinet and opened it. There were several narcotic medication cards inside. […]

• No harm, potential for more than minimal, patternF656May 7, 2026

  Based on observation, interview, and record review the facility failed to develop, and implement a comprehensive care plan to meet the medical, nursing, mental and psychosocial needs for 5 of 13 residents reviewed for care plans. (Resident #41, Resident #84, Resident #09, Resident #98, and Resident # 108)The facility failed to include in the care plan services Resident # 41 was a 2-person transfer with a Mechanical lift.The facility failed to include in the care plan services refused by Resident # 84 (left hand splints and dietary recommendations).The facility failed to develop and implement Resident #9's care plan for upper and lower extremity limited ROM.The facility failed to develop and implement Resident #98's care plan for wandering.The facility failed to develop and implement… […]

• No harm, potential for more than minimal, patternF756May 7, 2026

  Based on observations, interviews and record review, the facility failed to act upon the recommendations of the pharmacies report of irregularities for 3 of 7 residents (Resident #1, #88 and #108) reviewed for (DRR) Drug Regimen Review. 1.The facility failed to ensure a proper rationale was given for not following the pharmacy consultant's recommendation for a trial dose reduction for Resident #1's Oxcarbazepine (an anticonvulsant medication sometimes used off-label as a mood stabilizer), Trazodone (an antidepressant commonly used to treat major depressive disorder, anxiety disorders, and insomnia), and Alprazolam (a benzodiazepine used to treat anxiety disorders, panic disorders, and anxiety associated with depression). […]