Transitions Healthcare Autumn Grove Care Center

In the surveyor’s words

From the most serious findings on record at Transitions Healthcare Autumn Grove Care Center, in the surveyor’s own words.

• Immediate jeopardy, widespreadF836Nov 15, 2023

  Based on review of facility policy, clinical records, facility documents, staff documentation, and coroner's report and staff interviews, it was determined the facility failed to provide emergency life-saving interventions as required for one resident who was choking and still breathing where professional licensed staff did not attempt life-saving interventions to Resident R1 as required. This failure placed all 100 residents that may have needed emergency life-saving interventions, at a high risk for death and resulted in an Immediate Jeopardy situation. […]

• Immediate jeopardy, widespreadF584Jun 2, 2022

  Based on observations, review of facility policy and documents, and staff and resident interviews it was determined that the facility failed to maintain a temperature range between 71 to 81 degrees Fahrenheit in 49 of 51 occupied resident rooms, resulting in immediate jeopardy to the residents. Findings include: Review of the facility Emergency Disaster Plan manual revealed it lacked a policy/procedure for the facility to follow in the instance of air conditioning failure. During an interview on 6/01/22, at 3:55 p.m. […]

• Immediate jeopardy, patternF805Nov 15, 2023

  Based on review of clinical records, facility documents and coroner's report, and staff interviews it was determined the facility failed to provide food in a form designed to meet individual needs for one resident (Resident R1) who choked and ceased to breath as a result. This failure placed nine residents that had similar diet needs for bite-sized pieces at a high risk for death and resulted in an Immediate Jeopardy situation for Residents R2, R3, R4, R5, R6, R7, R8, R9, and R10. Findings include: Review of Resident R1's clinical record revealed an admitted [DATE], with diagnoses that included alcoholic myopathy, muscle weakness, unsteadiness on feet, and dysphagia (difficulty swallowing). […]

• No harm, potential for more than minimal, widespreadF802Sep 14, 2023

  Based on review of facility grievances and resident council minutes, observations and resident and staff interviews, it was determined that the facility failed to provide sufficient staff to carry out the functions of the food and nutrition services in the main kitchen and delay of meal service to residents. Findings include: Review of the tray line delivery times dated 1/18/22, revealed A Wing residents (the last unit delivered) were scheduled to receive their lunch at 12:00 p.m. Review of the June Resident Council Minutes indicated concerns voiced regarding meal times. […]

• No harm, potential for more than minimal, widespreadF812Sep 14, 2023

  Based on review of facility policies, observations, and staff interview, it was determined the facility failed to properly store foods/maintain proper sanitation in the main kitchen. Findings include: Review of facility policy entitled, Cleaning Dishes/Dish Machine last reviewed 8/03/23, revealed that Low Temperature Dishwasher using chemicals to sanitize that the wash temperature should be 120 degrees Farenheit and that the final rinse sanitization should be at 50 parts per million (50 PPM). […]