Autumnwood Nursing & Rehab Center

In the surveyor’s words

From the most serious findings on record at Autumnwood Nursing & Rehab Center, in the surveyor’s own words.

• Actual harm, isolatedF604May 27, 2025

  Based on closed medical record review, review of a facility self-reported incident (SRI), review of facility policy, and interview the facility failed to ensure Resident #52 was free from physical restraints. Actual Harm occurred on 03/08/25 at approximately 7:00 A.M. when Resident #52 was physically restrained and tied to his wheelchair with a bed sheet by Licensed Practical Nurse (LPN) #526 in an attempt to address Resident #52's behaviors and to prevent Resident #52 from standing from the chair. Resident #52 was found by visiting Hospice LPN #603 tied to his wheelchair with a bed sheet knotted behind him. The resident was unattended, seated in his wheelchair, agitated, and reported a pain rating of a 10 on a one-to-ten scale (with ten indicating the worst possible pain). […]

• Actual harm, isolatedF689May 27, 2025

  Based on observations, resident and staff interview, record review, and review of the facility policy, the facility failed to ensure safety measures and interventions were implemented to prevent potential accidents and hazards. Actual Harm occurred to Resident #21 on 02/01/25 when the facility failed to ensure Resident #21's smoking apron was in place during smoking and Resident #21 sustained a burn from his cigarette dropping on his right thigh. The burn had full thickness tissue loss with 100 percent (%) slough (dead tissue) in the wound bed, and required debridement. […]

• No harm, potential for more than minimal, widespreadF727May 27, 2025

  THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, interview, and the facility submitted Payroll Based Journal (PBJ) tracking information, the facility failed to ensure a registered nurse (RN) was on duty for at least eight consecutive hours a day, seven days a week as required. This had the potential to affect all 54 residents residing in the facility. Findings include: Review of the PBJ Staffing Data Report form submitted from 07/01/24 through 09/30/24 revealed the following dates submitted for the third quarter of the fiscal year 2024, the facility was low on RN hours in the building on the seven following dates: 07/26/25, 07/31/25, 08/01/25, 08/05/25, 08/10/25, 08/11/25, and 08/28/25. […]

• No harm, potential for more than minimal, widespreadF804May 27, 2025

  Based on record review, resident and staff interviews, and observation of a test tray, the facility failed to serve foods at a palatable temperature. This had the potential to affect all 54 residents residing in the facility who receive food from the kitchen. Findings include: Review of the diet order listing report revealed there were no residents with orders for nothing by mouth (NPO) and all 54 residents had oral diet orders in place. On 05/12/25 at 8:13 A.M., an interview with Resident #36 stated the food was awful. On 05/12/25 at 10:31 A.M., an interview with Resident #25 stated the food was cold. On 05/12/25 at 11:40 A.M., an interview with Resident #153 stated the food was horrible. On 05/14/25 from 10:49 A.M. […]

• No harm, potential for more than minimal, widespreadF812May 27, 2025

  Based on record review, interview, observations, review of chemical sanitizer directions for use, and review of dishwasher manufacturer's directions, the facility failed to properly sanitize dishware after washing, discard expired foods in a timely manner, and maintain food storage areas in a clean manner. This had the potential to affect all 54 residents residing at the facility who receive food from the kitchen. Findings include: Review of the diet order listing report revealed there were no residents with orders for nothing by mouth (NPO) and all 54 residents had oral diet orders in place. […]