A list of the most recent deficiencies for Autumn Lake Healthcare at Madison. 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? |
|---|---|---|---|---|
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-09-27 | 2023-11-30 | Y |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2023-09-27 | 2023-11-30 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-06-14 | 2023-07-21 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-02-27 | 2023-04-14 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-01-17 | 2023-03-10 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-11-03 | 2022-11-22 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-09-23 | 2022-10-12 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-01-10 | 2022-10-03 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-01-10 | 2022-10-03 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-08-20 | 2022-08-15 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-08-20 | 2022-08-15 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-06-30 | 2022-08-04 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-06-30 | 2022-08-04 | Y |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2022-06-30 | 2022-08-04 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-06-13 | 2022-07-08 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-06-13 | 2022-07-08 | Y |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2022-06-13 | 2022-07-08 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2022-04-19 | 2022-06-01 | Y |
| 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 | 2022-04-19 | 2022-06-01 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-04-19 | 2022-06-01 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-04-19 | 2022-06-01 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-04-19 | 2022-06-01 | Y |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2021-07-14 | 2021-08-03 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-07-14 | 2021-08-03 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-07-14 | 2021-08-03 | 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 | 2021-07-14 | 2021-08-03 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-07-14 | 2021-08-03 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-07-14 | 2021-08-03 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2021-07-14 | 2021-08-03 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-07-14 | 2021-08-03 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-03-19 | 2021-04-18 | Y |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2021-03-19 | 2021-04-18 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-03-19 | 2021-04-18 | Y |
| Provide properly protected cooking facilities. | Fire Safety | 2019-03-27 | 2019-06-03 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-03-27 | 2019-06-03 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-03-27 | 2019-06-03 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-03-27 | 2019-06-03 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2019-03-28 | 2019-05-02 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-03-28 | 2019-05-02 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2019-03-28 | 2019-05-02 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-03-28 | 2019-05-02 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-03-28 | 2019-05-02 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-03-28 | 2019-05-02 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2019-03-28 | 2019-05-02 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2019-03-28 | 2019-05-02 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2018-02-02 | 2018-03-16 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2018-02-02 | 2018-03-16 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-02-02 | 2018-03-16 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-02-02 | 2018-03-16 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-02-02 | 2018-03-16 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-02-02 | 2018-03-16 | N |
| Have an externally vented heating system. | Fire Safety | 2018-01-30 | 2018-03-13 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-01-30 | 2018-03-13 | N |
