The Subacute at Autumn Lake Healthcare

In the surveyor’s words

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

• Immediate jeopardy, isolatedF684Sep 26, 2025

  Complaint #: 398977Based on record review, interview, and document review, the facility failed to notify the physician of a resident's refusal to have an immediate (STAT) laboratory test on [DATE] and [DATE]; failed to obtain a Urine with Culture and Sensitivity (C&S) test when ordered on [DATE]; failed to monitor the resident after reports of nausea without emesis for three days, decreased appetite secondary to the nausea, and continued diarrhea; and failed to act upon a critically high white blood cell (WBC) count for one of 16 sampled residents (Resident (R) 7). […]

• Immediate jeopardy, isolatedF697Sep 26, 2025

  Complaint #: 398975Based on record review, interview, and document review, the facility failed to consistently provide pain management for one of 16 sampled residents (Resident (R)16). R16 was admitted to the facility with diagnoses including pancreatic adenocarcinoma and had admitting orders for pain medications, in particular Dilaudid (an opioid pain medication used to treat moderate to severe pain), and staff failed to administer the medication as ordered. R16 had pain levels up to a 10 (on a zero to 10 scale, with 10 being the most intense pain possible). […]

• Immediate jeopardy, isolatedF755Sep 26, 2025

  Complaint #: 398975Based on record review, interview, and document review, the facility failed to acquire pain medications as ordered by the physician for one of 16 sampled residents (Resident (R)16). R16 was admitted to the facility with diagnoses including pancreatic adenocarcinoma and had admitting orders for pain medications, in particular Dilaudid (an opioid pain medication used to treat moderate to severe pain), and staff failed to acquire the medication. This failure of R16 not receiving the ordered medication for pain caused harm and increased the likelihood for a painful death.The facility's Administrator, Director of Nursing (DON), and Regional Nurse Consultant (RNC) were informed on 09/25/25 at 7:40 PM an Immediate Jeopardy (IJ) existed at F755 Pharmacy Services related to the… […]

• Immediate jeopardy, isolatedF808Nov 27, 2024

  Complaint #: NJ00180094 Based on interviews, medical record review, and review of other pertinent facility documentation on 11/26/2024 and 11/27/2024, it was determined that: the facility failed to provide the correct therapeutic diet to a cognitively impaired resident (Resident #3) with a known diagnosis of dysphagia, pharyngeal phase who had a physician's order and plan of care for ground diet and required feeding assistance. It was determined that on 11/12/2024 a Certified Nursing Assistant (CNA) delivered a meal tray containing a regular texture meal to Resident #3, who had orders for a ground diet. The regular texture meal was left with Resident #3. The CNA confirmed that Resident #3's meal tray included corn and tortillas that were not ground texture. […]

• Actual harm, isolatedF689Jun 10, 2021

  Complaint # NJ 015 Based on interview, review of medical records and other pertinent facility documentation it was determined that the facility failed to ensure: a.) the facility policy for the management of residents at risk for falls was followed, b.) a resident admitted to the facility with a known history of falls was assessed as a fall risk, c.) staff developed a care plan (CP) for falls and implemented interventions to reduce the risk for injury from falls. This deficient practice was identified for 1 of 1 residents reviewed for accidents (Resident #262), who fell on [DATE] at 18:40 hours (6:40 PM) and hit his/her head. The resident had a subsequent fall on 04/25/21 at 15:56 (3:56 PM) and sustained a laceration to the left elbow. […]