Autumn House of York

Medication containers containing resident names, medication regimens, and diagnoses were found unlocked and unattended in a trash bin on a medication cart.

Mold spores were observed lining a ceiling vent in the 3000-hall.

Evidence of a mouse infestation was found, including a mouse sighting in a common shower room and mouse droppings in a resident's room.

Multiple resident-to-resident incidents occurred involving physical aggression, including slapping, pushing, and pulling, resulting in physical marks and injuries.

The home failed to report an incident involving a resident being pulled from a chair to the Department within the required 24-hour timeframe.

Sanitary conditions were inadequate, including a dead mouse on an exterior landing, mold in a ceiling vent, blood on a mattress, and a tooth on the floor.

Violation regarding resident records or documentation.

Violation regarding resident census or documentation requirements.

During the overnight shift, only one staff member was present who was certified in First Aid and CPR, failing to meet the required ratio.

Discontinued medications were found on a medication cart in the hallway.

Multiple incidents of resident neglect and physical harm occurred, including a resident being pushed onto the floor and another sustaining a cut to the arm.

Multiple incidents of resident altercations and physical harm occurred, including residents sustaining scratches, skin tears, and burns from hot coffee.

During an overnight shift with 92 residents, only 7 staff members present were certified in First Aid and CPR.

Staff failed to document required 15-minute checks for a resident's irritability and aggression on multiple shifts.

Multiple incidents of physical abuse and mistreatment were observed, including residents punching and choking another resident.

The home's written policy for reportable incidents did not include conducting investigations or gathering witness statements.

Cigarette butts were observed in the mulch bed outside the entrance, and a staff member was observed smoking on the sidewalk.

A small yellow tablet was found unlocked, unattended, and accessible on the floor outside of the hallway medication area.

Copies of the chapter and the current licensing inspection summary were not posted in a conspicuous and public place.

A resident requiring 24-hour supervision eloped from the secured dementia care unit and was found by police blocks away.