Deficiency Records for Autumn Lake Healthcare at Ballenger Creek
Updated as of April 01, 2024
A list of the most recent deficiencies for Autumn Lake Healthcare at Ballenger Creek. 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 each resident receives an accurate assessment. | Health | 2022-11-15 | 2023-02-16 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-11-15 | 2023-02-16 | 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 | 2022-11-15 | 2023-01-16 | 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 | 2022-11-15 | 2023-01-16 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-11-15 | 2023-01-16 | N |
| Ensure the activities program is directed by a qualified professional. | Health | 2022-11-15 | 2023-01-16 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2022-11-15 | 2023-01-16 | N |
| Post nurse staffing information every day. | Health | 2022-11-15 | 2023-01-16 | 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 | 2022-11-15 | 2023-01-16 | 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 | 2022-11-15 | 2023-01-16 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2022-11-15 | 2023-01-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-11-15 | 2023-01-16 | N |
| Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Health | 2022-11-15 | 2023-01-16 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-11-15 | 2023-01-16 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-11-15 | 2023-01-16 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-11-15 | 2023-01-16 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-11-15 | 2023-01-16 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-11-15 | 2023-01-16 | Y |
| Provide activities to meet all resident's needs. | Health | 2022-11-15 | 2023-01-16 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-11-15 | 2023-01-16 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-11-15 | 2023-01-16 | Y |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2022-11-15 | 2023-01-16 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-11-15 | 2023-01-16 | Y |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2022-11-15 | 2023-01-16 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-11-02 | 2022-12-15 | N |
| Construct fire resistant interior walls. | Fire Safety | 2022-11-02 | 2022-12-15 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-11-02 | 2022-12-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-11-02 | 2022-12-15 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-11-02 | 2022-12-15 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-11-02 | 2022-12-15 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-11-02 | 2022-12-15 | N |
| Ensure that residents are free from significant medication errors. | Health | 2022-11-15 | 2022-11-15 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-02-09 | 2022-04-08 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2022-02-09 | 2022-04-08 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-10-22 | 2021-12-05 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2018-11-19 | 2019-01-02 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-11-19 | 2019-01-02 | 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 | 2018-11-19 | 2019-01-02 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-11-19 | 2019-01-02 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-11-19 | 2019-01-02 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2018-11-19 | 2019-01-02 | 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 | 2018-11-19 | 2019-01-02 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-11-19 | 2019-01-02 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2018-11-19 | 2019-01-02 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-11-19 | 2019-01-02 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-11-19 | 2018-11-30 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2018-04-18 | 2018-06-01 | N |
| 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 | 2018-04-18 | 2018-06-01 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2018-04-18 | 2018-06-01 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-04-18 | 2018-06-01 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-04-18 | 2018-06-01 | 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 | 2018-04-18 | 2018-06-01 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2018-04-18 | 2018-06-01 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2018-04-18 | 2018-06-01 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-04-18 | 2018-06-01 | 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 | 2018-04-18 | 2018-06-01 | N |
| Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. | Health | 2018-04-18 | 2018-06-01 | 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 | 2018-04-18 | 2018-06-01 | 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 | 2018-04-18 | 2018-06-01 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-04-18 | 2018-06-01 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2018-04-18 | 2018-06-01 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2018-04-11 | 2018-05-21 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2018-04-11 | 2018-05-21 | N |
