Autumn Lake Healthcare At Waugh Chapel

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on complaint, reviews of a closed medical record, and staff interview, it was determined that the nursing staff failed to follow a physician's orders for withholding an antihypertensive medication when the resident's blood pressure reading was less than 110 mm/Hg.

This was evident for 1 of 2 residents (Resident #1) reviewed during the complaint survey.The findings include:Review of Complaint 2605041 on 11/19/25 at 12 noon revealed an allegation Resident #1 was not receiving quality of care at the facility.Resident #1 was admitted to the facility on [DATE] with diagnoses that include but are not limited to post vascular surgery, arthritis, and hypertension. Resident #1 requires assistance from the nursing staff for some aspects of his/her care.Review of Resident #1's closed medical record on 11/19/25 at 12 noon revealed a physician order, dated 08/09/25, instructing the nursing staff to administer the blood pressure lowering medication, Amlodipine Besylate oral tablet, 2.5 mg, by mouth, one time a day, and hold for a systolic blood pressure reading less than 110 mm/Hg.A review of Resident #1's August and September 2025 Medication Administration Records (MAR) revealed the nursing staff were administering a dose of Amlodipine Besylate at 9 AM when Resident #1 blood pressure readings were less than 110 mm/Hg on the following days:08/11/2025 - 109/74.08/12/2025 - 109/74.08/14/2025 - 106/70.08/25/2025 - 106/70.08/28/2025 109/70.09/04/2025 - 100/60.In an interview with Staff Nurse #1 on 11/19/2025 at 3:40 PM, after reviewing Resident #1's August and September MAR's, Staff Nurse #1 stated that s/he should have withheld administering the dose of Amlodipine Besylate, 2.5 mg orally, to Resident #1 on 08/11/25, 08/14/25, 08/25/25, 08/28/25, and 09/04/25 due to Resident #1's blood pressure reading was less than 110 mm/Hg.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.

For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

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