Nella's at Autumn Lake Healthcare

In the surveyor’s words

From the most serious findings on record at Nella's at Autumn Lake Healthcare, in the surveyor’s own words.

• Immediate jeopardy, widespreadF689Aug 5, 2025

  Based on observation, record review, and staff interview, the facility failed to ensure the environment over which it had control was as free from accident hazards as possible. Hot water temperatures in resident areas exceeded 120 degrees Fahrenheit (F). This deficient practice was determined to be an immediate jeopardy situation that placed all residents at risk for burns from hot water. Facility census: 91.Findings included:a) Hot water temperatures The facility's policy statement titled Safe Water Temperatures, with no implementation or revision dates given, stated as follows:Direct care staff will monitor residents during prolonged exposure to to warm or hot water for any signs or symptoms of burns, and will respond appropriately. […]

• Immediate jeopardy, patternF600Nov 8, 2023

  Based on resident interview, record review, and staff interview, the facility failed to ensure residents were free from sexually aggressive behavior (such as making sexually explicit comments and forced observation of masturbation and exposure ) from Resident #59. The lack of action from the facility to address and protect the other residents resulted in an immediate jeopardy situation for more than an isolated number of residents. The facility was notified of the immediate jeopardy on 11/07/23 at 5:01 PM. The plan of correction, as follows, was accepted at 6:57 PM on 11/07/23: -Resident #59 will be placed on 24 hour, one on one supervision effective 5:00 pm on November 7, 2023, to protect all residents. […]

• No harm, potential for more than minimal, widespreadF801Dec 30, 2025

  Based on interview and record review, the facility failed to employ a Certified Dietary Manager with appropriate credentials. The facility also failed to ensure that the Nutrition Services Staff had the County / State specified certification for safe handling of food. This deficient practice had the potential to affect all residents receiving meals in the facility. Facility Census: 96.Findings included:During an interview, on 12/29/25 at 12:35 PM, the surveyor asked Food Service Manager (FSM) #61 if he was a Certified Dietary Manager (CDM), and he stated, No I am not. The surveyor asked if they had a full-time Registered Dietician (RD) on staff, and he said No. […]

• No harm, potential for more than minimal, widespreadF812Dec 30, 2025

  Based on observation and staff interview, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food safety. Additionally, the facility failed to maintain the equipment in safe and clean operating condition. This practice had the potential to affect all of the residents at the facility. Facility census: 96.Findings included:a) During a walkthrough of the kitchen on 12/29/25 at 12:40 PM there were multiple cases of disposable utensils, plates and cups sitting directly on the floor. […]

• No harm, potential for more than minimal, widespreadF880Dec 30, 2025

  Based on observation and staff interview, the facility failed to establish and maintain an infection prevention and control program designed to provide a sanitary environment to help prevent the development and transmission of communicable diseases and infections by not having paper towels at (2) two of the handwashing sinks in the kitchen. This failed practice had the potential to affect all residents currently living at the facility. Facility Census: 96.Findings included:a) During a walkthrough of the kitchen, on 12/29/25 at 12:50 PM, this surveyor washed his hands at the handwashing sink outside of the Food Services Manager's (FSM) office inside the kitchen and there were no paper towels to dry my hands. The FSM said, Someone must have used the last one and did not refill them. […]