A list of the most recent deficiencies for Autumn Breeze Health and Rehab. 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? |
|---|---|---|---|---|
| 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 | 2022-11-14 | 2023-01-10 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-11-14 | 2023-01-10 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-11-14 | 2023-01-10 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-11-14 | 2023-01-10 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-11-14 | 2023-01-10 | Y |
| 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 | 2022-11-14 | 2023-01-10 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2022-11-14 | 2023-01-10 | Y |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2022-11-14 | 2023-01-10 | Y |
| Develop, implement, and/or maintain an effective training program for all new and existing staff members. | Health | 2022-11-14 | 2023-01-10 | Y |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-11-15 | 2023-01-10 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-11-15 | 2023-01-10 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-11-15 | 2023-01-10 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-11-15 | 2023-01-10 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-11-15 | 2023-01-10 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-04-29 | 2021-06-13 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-04-29 | 2021-06-13 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-04-29 | 2021-06-13 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2019-03-14 | 2019-04-28 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2019-03-14 | 2019-04-28 | N |
| 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 | 2019-03-14 | 2019-04-28 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-03-14 | 2019-04-28 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-03-12 | 2019-04-28 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2019-03-12 | 2019-04-28 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-03-12 | 2019-04-28 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2019-03-12 | 2019-04-28 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-03-12 | 2019-04-28 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-03-12 | 2019-04-28 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-03-12 | 2019-04-28 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-03-12 | 2019-04-28 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2019-03-12 | 2019-04-28 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-03-12 | 2019-04-28 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-04-29 | Not Fixed | N |
