Autumn Ridge Rehabilitation Centre

In the surveyor’s words

From the most serious findings on record at Autumn Ridge Rehabilitation Centre, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Apr 12, 2021

  Based on record review and interview the facility failed to ensure a resident with dysphagia and at risk for choking received supervision while eating for 1 of 4 residents at risk for choking. This deficient practice resulted in the resident choking, coded and the emergency services being called and the resident hospitalized . The resident later died on [DATE]. (Resident B). The immediate jeopardy began on [DATE] when a Dietary Aide served Resident B a tray of food and left the resident with no assistance or supervision. The Administrator and Nurse Consultant were notified of the immediate jeopardy at 1:11 p.m. on [DATE]. […]

• Immediate jeopardy, isolatedF803Apr 12, 2021

  Based on record review and interview the facility failed to ensure a resident with dysphagia and at risk for choking received a diet in the correct form for 1 of 4 residents reviewed for a risk of choking. This deficient practice resulted in the resident choking, coding and the emergency services being called and resident hospitalized . The resident later died on [DATE]. (Resident B). The immediate jeopardy began on [DATE] when a Dietary Aide served Resident B a tray of food that was not in the correct form and left the resident to eat. The Administrator and Nurse Consultant were notified of the immediate jeopardy at 1:11 p.m. on [DATE]. […]

• No harm, potential for more than minimal, patternF575Mar 31, 2026

  Based on observation and interview, the facility failed to ensure required State Agency and Ombudsman contact information was prominently displayed in a location and manner accessible to residents, specifically those utilizing wheelchairs. This deficient practice affected 3 of 3 residents reviewed for resident rights and had the potential to affect 21 residents residing on the 3rd floor of the facility. (Residents 5, 7, and 10)Findings include:During a Resident Council group interview, on 3/25/26 at 2:00 p.m., Residents 5, 7, and 10 each indicated they did not know where to find information for the local Ombudsman or where to find information about how to contact the State Agency with concerns. Resident 5 indicated he could ask the Activities Director (AD) for the information. […]

• No harm, potential for more than minimal, isolatedF561Mar 31, 2026

  Based on observation, interview, and record review, the facility failed to protect residents' rights to choose to move within the facility and to spend time outdoors as able for 3 of 3 residents of 21 residents residing on the third floor reviewed for residents' rights. (Residents 5, 7, and 10)Findings include:During a Resident Council group interview, on 3/25/26 at 2:00 p.m., Residents 5, 7, and 10 each indicated the facility placed significant restrictions on their mobility and autonomy. The residents who lived on the third floor were prohibited from accessing the first floor or the outdoor patio without staff supervision. Key barriers included an elevator that required a keypad code, which had not been shared with the residents, and a locked exterior door leading to the patio. […]

• No harm, potential for more than minimal, isolatedF677Mar 31, 2026

  Based on observation, interview and record review, the facility failed to ensure residents received bathing assistance according to their assessed needs and preferences for 1 of 1 resident reviewed for activities of daily living (ADLs). (Resident 7) Findings include:On 3/24/26 at 12:45 p.m., during the lunch meal, Resident 7 was observed seated at a dining table. Resident 7's hair was greasy and disheveled.During the Resident Council group interview, on 3/25/26 at 2:04 p.m., Resident 7 indicated she had not received a shower for over a week. Her hair was still greasy and stringy, and she was wearing the same clothes from the day before. Saturdays and Tuesdays were her scheduled shower days, but she did not receive a shower on either scheduled day. […]