Autumn Woods Health Campus

In the surveyor’s words

From the most serious findings on record at Autumn Woods Health Campus, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jul 21, 2023

  Based on observation, interview and record review, the facility failed to ensure a resident (Resident B) on the secured dementia unit with exit seeking behaviors did not exit the facility without supervision for 1 of 3 residents reviewed for supervision. This deficient practice resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 7/17/23 when a resident exited the 300 Hall door on the dementia unit by pressing on the egress bar which sounded the alarm and opened after 15 seconds. After the resident exited the facility, he turned left and ambulated in a straight line up a small hill then down a hill which led to the apartments adjacent from the facility. The resident was off the facility property. […]

• Immediate jeopardy, isolatedF689Mar 21, 2022

  Based on record review and interview, the facility failed to ensure adequate supervision was in place when a cognitively impaired resident with dementia and a wander guard in place exited the facility on 3/8/22 without supervision through an unknown point of exit. The resident was picked up by a stranger from a parking lot of an apartment complex next to the facility and transported to the local hospital. This deficient practice resulted in Immediate Jeopardy. The Immediate Jeopardy began on 3/8/22 when a cognitively impaired resident with dementia exited the facility without facility knowledge. The Executive Director (ED), Director of Nursing (DON), Campus Support Clinical, and Assistant Vice President of Clinical were notified of the Immediate Jeopardy on 3/15/22 at 12:17 p.m. […]

• Actual harm, isolatedF686Mar 21, 2022

  Based on, observation, record review, and interview, the facility failed to ensure interventions and assessments were implemented to prevent the development or worsening of new pressure ulcers for 1 of 5 residents reviewed for pressure ulcers, which resulted in the development of unstageable pressure ulcers to the residents right heel and foot. Findings include: On 3/14/22 at 9:40 a.m., Resident 54 was lying in bed on her back with her breakfast tray in front of her on a bedside table. There was no pillow or wedge under her calves. She had on socks and her legs were wrapped with a rolled gauze. The resident's heels were lying directly on the mattress. On 3/16/22 at 1:13 p.m., the resident was lying in bed on her back. […]

• No harm, potential for more than minimal, patternF880May 1, 2026

  Based on observation, record review, and interview, the facility failed to ensure glucometers (portable device used to measure blood sugar levels) were cleaned per manufacturer guidelines for infection control when obtaining blood sugar readings for 3 of 3 residents observed. (Residents 11, 39, and 34) Findings include:1. During an observation, on 4/29/26 at 8:14 a.m., Licensed Practical Nurse (LPN) 4 obtained Resident 11's blood sugar reading, using the glucometer. After the resident's blood sugar reading was completed, LPN 4 returned to the medication cart with the glucometer. She obtained the bleach wipe, and the glucometer was wrapped in the bleach wipe for two minutes, without cleaning or wiping down the glucometer. […]

• No harm, potential for more than minimal, patternF689Apr 4, 2025

  Based on observation, record review, and interview, the facility failed to ensure appropriate interventions were implemented to prevent falls for 5 of 7 residents reviewed for accidents. (Residents 73, 57, 51, 55, and 12) Findings include: 1. During an interview, on 4/1/25 at 10:17 a.m., Resident 73's family member indicated when the resident was in a room on the Legacy Lane Unit, while being transferred from the wheelchair to the bed, a fall occurred. A lift chair was supposed to have been used and the Certified Nurse Aides (CNAs) decided to transfer Resident 73 from the shower to the bed in a wheelchair. There were no peddles on the wheelchair and the resident's feet dropped to the floor. […]