Autumn Woods Residential Health

In the surveyor’s words

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

• Actual harm, patternF684May 4, 2022

  Based on observation, interview and record review, the facility failed to implement effective interventions to manage constipation, and monitor bowel patterns for three Residents (Resident #72, #123 and #200) of five reviewed for a change in condition, resulting in an immediate jeopardy (IJ) with the likelihood of serious injury, harm and/or death. Findings include: Resident #72 On 04/26/2022 at 09:48 AM, Resident #72 was awake in bed. Resident #72 had a hospital gown on, and observed to have bilateral contracted hands. The Resident made eye contact and smiled when spoken to, but was unable to answer questions appropriately. Resident #72's abdomen was visible underneath their gown and was round and protruding. […]

• Actual harm, isolatedF600Aug 18, 2022

  This citation pertains to intake MI 978. Based on interview and record review, the facility failed to prevent resident to resident physical abuse of Perpetrator Resident (R906) towards one Resident (R907) out of two residents reviewed for abuse, resulting in hospitalization requiring stitches, severe pain, and mental anguish utilizing the reasonable person concept. Findings Include: On 8/17/2022 at 9:00 AM, R907 was observed resting in bed. An interview was attempted, however, R907 did not wake up or respond to verbal communication. A review of the medical record revealed that R907 admitted into the facility on [DATE] with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• Actual harm, isolatedF697May 4, 2022

  Based on observation, interview, and record review the facility failed to manage pain, ensure medication was administered as ordered, and ensure ordered pain medication was available for one sampled Resident (R161), resulting in ongoing and untreated pain. Findings include: On 4/26/22 at 9:36 AM, R161 was observed laying on their right side in bed. R161 was asked about their stay at the facility and stated, I'm in pain, I have hemorrhoids and haven't gotten any medication all day. This has happened more than once. I'm in pain. I feel like screaming and swearing. […]

• Actual harm, isolatedF686Dec 20, 2021

  This citation pertains to intake numbers: MI 801, MI 868 and MI 949. Based on observation, interview and record review, the facility failed to assess and monitor wounds/skin and/or reposition per standards of care for three of three Residents (Resident #900, #901 and #902) reviewed for pressure ulcers (a wound formed over a bony prominence from prolonged pressure to the area), resulting in the development of new wounds, the potential of worsening wounds, pain, and hospitalization . Findings include: Resident #902 (R902) On 12/16/2021 at 10:44 AM, an interview was completed via telephone with Confidential Witness D. According to Confidential Witness D, Resident #902 was currently in the hospital. […]

• No harm, potential for more than minimal, widespreadF812Jul 25, 2024

  Based on observation, interview, and record review, the facility failed to maintain the sanitizer buckets, failed to ensure dishware was dry before stacking, and failed to ensure resident food items were dated. This deficient practice had the potential to affect all residents that consume food from the kitchen. Findings include: On 7/23/24 between 8:55 AM-9:30 AM, during an initial tour of the kitchen with Dietary Staff P, the following items were observed: There were 2 red sanitizer buckets with wiping cloths inside observed in the kitchen area. Dietary Staff P stated the buckets contained sanitizer solution. The sanitizer level in both buckets was tested with a test strip, and the strip did not change color to denote the presence of sanitizer solution in the buckets. […]