Autumn Oaks Caring Center

In the surveyor’s words

From the most serious findings on record at Autumn Oaks Caring Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jan 10, 2025

  Based on interview and record review, the facility failed to ensure the residents environment was free from accident hazards as possible and failed to ensure all residents that required supervision during food consumption were supervised for one resident (Resident #36), of five sampled residents, when staff left the resident, who had an ordered pureed diet and was care planned for supervision while eating, access to an non-resident use area with food, resulting in the resident attempting to consume non-pureed food, choking, and being intubated. The facility census was 67. The facility Administrator, Director of Nursing (DON), and Regional Nurse Consultant were informed on 01/07/25, at 7:05 P.M., the an Immediate Jeopardy (IJ) which began on 01/03/25. […]

• Immediate jeopardy, isolatedF684Jun 2, 2023

  Based on observation, interview, and record review, the facility failed to provide care in accordance with professional standards when facility staff failed to complete a full assessment and monitor a newly admitted resident (Resident #53), who experienced labored breathing and passed away after arrival to the facility. A sample of 21 residents was reviewed in a facility with a census of 57. The Administrator, Director of Nursing (DON), Regional Nurse, and Corporate Director of Operations were notified on [DATE], of the Past Non-Compliance which occurred on [DATE]. […]

• Actual harm, isolatedF692Jan 10, 2025

  Based on interview, observation, and record review, the facility failed to provide care and services to maintain acceptable parameters of nutritional status, when staff failed to follow-up on and implement multiple weight loss interventions for one resident (Resident #2), of nine sampled residents reviewed for weight loss, who had a significant weight loss. The facility census was 67. 1. Review of Resident #2's Admission Record, located under the Profile tab of the electronic medical record (EMR), showed the resident admitted on [DATE]. […]

• No harm, potential for more than minimal, widespreadF812Jun 2, 2023

  Based on observation, interview, and record review, the facility failed to ensure food was stored, prepared, and distributed in a manner to prevent possible contamination when staff failed to maintain food contact services as clean and failed to dispose of foods with expired dates. This had the potential to affect all residents who consumed food from the facility kitchen. The facility census was 57. 1. Review of the 2013 Missouri Food Code showed food-contact surfaces of equipment and utensils shall be clean to sight and touch. […]

• No harm, potential for more than minimal, patternF690Oct 18, 2023

  Based on observation, interview, and record review, the facility failed to ensure all residents with catheters (a sterile tube inserted into the bladder to drain urine) received treatment and services in a manner to prevent urinary tract infections (UTI) when staff failed to document providing catheter care per physician's orders for three residents (Residents #1, #2, and #3) and failed to obtain a physician's order for a catheter for one resident (Resident #1). Two resident (Resident #1 and #3) had a history of UTIs. A sample of five residents was reviewed in a facility with a census of 75. […]