A list of the most recent deficiencies for Autumn Hills Health Care Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-10-16 | 2023-11-14 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-30 | 2023-04-24 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-03-30 | 2023-04-24 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-11-14 | 2022-12-02 | N |
| Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. | Health | 2022-11-14 | 2022-12-02 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-11-14 | 2022-12-02 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-03-20 | 2022-04-14 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-03-20 | 2022-04-14 | N |
| Honor each resident's preferences, choices, values and beliefs. | Health | 2022-03-20 | 2022-04-14 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2022-03-20 | 2022-04-14 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-03-20 | 2022-04-14 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-03-20 | 2022-04-14 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2022-03-20 | 2022-04-14 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-03-20 | 2022-04-14 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-03-20 | 2022-04-14 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2022-03-20 | 2022-04-14 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2022-03-20 | 2022-04-14 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-03-20 | 2022-04-14 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2022-03-20 | 2022-04-14 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-03-20 | 2022-04-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-03-20 | 2022-04-14 | N |
| Implement a program that monitors antibiotic use. | Health | 2022-03-20 | 2022-04-14 | N |
| Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Health | 2021-04-13 | 2021-05-05 | Y |
| Provide properly protected cooking facilities. | Fire Safety | 2019-07-31 | 2019-09-03 | N |
| Construct fire resistant interior walls. | Fire Safety | 2019-07-31 | 2019-09-03 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2019-07-31 | 2019-09-03 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2019-07-31 | 2019-09-03 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-07-31 | 2019-09-03 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-07-31 | 2019-09-03 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-07-31 | 2019-09-03 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-08-01 | 2019-08-29 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-08-01 | 2019-08-29 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2019-08-01 | 2019-08-29 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-08-01 | 2019-08-29 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2019-08-01 | 2019-08-29 | N |
| Honor each resident's preferences, choices, values and beliefs. | Health | 2019-08-01 | 2019-08-29 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-08-01 | 2019-08-29 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-08-01 | 2019-08-29 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-08-01 | 2019-08-29 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-08-01 | 2019-08-29 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-08-01 | 2019-08-29 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2019-08-01 | 2019-08-29 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-08-01 | 2019-08-29 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2019-08-01 | 2019-08-29 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-08-01 | 2019-08-29 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-08-01 | 2019-08-29 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-08-01 | 2019-08-29 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2018-08-16 | 2018-09-10 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2018-08-16 | 2018-09-10 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2018-08-16 | 2018-09-10 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2018-08-16 | 2018-09-10 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2018-08-16 | 2018-09-10 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2018-08-16 | 2018-09-10 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-08-16 | 2018-09-10 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2018-08-16 | 2018-09-10 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-08-16 | 2018-09-10 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2018-08-16 | 2018-09-07 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2018-08-16 | 2018-09-07 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-08-16 | 2018-09-07 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2018-08-16 | 2018-09-07 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2018-08-16 | 2018-09-07 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2018-08-16 | 2018-09-07 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-08-16 | 2018-09-07 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2018-08-16 | 2018-09-07 | N |
| Implement a program that monitors antibiotic use. | Health | 2018-08-16 | 2018-09-07 | N |
| Keep all essential equipment working safely. | Health | 2018-08-16 | 2018-09-07 | N |
