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Deficiency Records for Autumn Lake Healthcare at Ballenger Creek
View the most recent health deficiencies and inspection results for Autumn Lake Healthcare at Ballenger Creek. Stay informed about quality of care issues.
View the most recent health deficiencies and inspection results for Autumn Lake Healthcare at Ballenger Creek. Stay informed about quality of care issues.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2025-11-20 | 2026-01-16 | Y |
| Respond appropriately to all alleged violations. | Health | 2025-11-20 | 2026-01-16 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2025-11-20 | 2026-01-16 | Y |
| 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 | 2025-11-20 | 2026-01-16 | Y |
| Meet other general requirements. | Fire Safety | 2025-06-30 | 2025-08-29 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2025-06-30 | 2025-08-29 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2025-06-30 | 2025-08-29 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2025-06-30 | 2025-08-29 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2025-06-30 | 2025-08-29 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2025-06-30 | 2025-08-29 | 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 | 2025-06-30 | 2025-08-29 | 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 | 2025-06-30 | 2025-08-01 | 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 | 2025-06-30 | 2025-08-01 | N |
| Provide activities to meet all resident's needs. | Health | 2025-06-30 | 2025-08-01 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2025-06-30 | 2025-08-01 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2025-06-30 | 2025-08-01 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2025-06-30 | 2025-08-01 | 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 | 2025-06-30 | 2025-08-01 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2025-06-30 | 2025-08-01 | N |
| Ensure that residents are free from significant medication errors. | Health | 2025-06-30 | 2025-08-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2025-06-30 | 2025-08-01 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2025-06-30 | 2025-08-01 | N |
| Provide and implement an infection prevention and control program. | Health | 2025-06-30 | 2025-08-01 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2025-06-30 | 2025-08-01 | Y |
| Respond appropriately to all alleged violations. | Health | 2025-06-30 | 2025-08-01 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2025-06-30 | 2025-08-01 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2025-06-30 | 2025-08-01 | Y |
| Assess the resident when there is a significant change in condition | Health | 2025-06-30 | 2025-08-01 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2025-06-30 | 2025-08-01 | 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 | 2025-06-30 | 2025-08-01 | 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 | 2025-06-30 | 2025-08-01 | N |
| 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 | 2025-06-30 | 2025-08-01 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2025-06-30 | 2025-08-01 | N |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2025-06-30 | 2025-08-01 | N |
| Keep all essential equipment working safely. | Health | 2025-06-30 | 2025-08-01 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2025-06-30 | 2025-08-01 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-11-15 | 2023-02-16 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-11-15 | 2023-02-16 | N |
| Respond appropriately to all alleged violations. | Health | 2022-11-15 | 2023-01-16 | N |
| 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 | N |
| 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 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | 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 |
| Provide activities to meet all resident's needs. | Health | 2022-11-15 | 2023-01-16 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-11-15 | 2023-01-16 | 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 | 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 |
| 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 |
| Post nurse staffing information every day. | Health | 2022-11-15 | 2023-01-16 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-11-15 | 2023-01-16 | N |
| 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 | 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 |
| 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 |
| 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 | 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 |
| 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 | 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 |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-11-15 | 2022-12-15 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-11-15 | 2022-12-15 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-11-15 | 2022-12-15 | N |
| Construct fire resistant interior walls. | Fire Safety | 2022-11-15 | 2022-12-15 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-11-15 | 2022-12-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-11-15 | 2022-12-15 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-11-15 | 2022-12-15 | N |
| Ensure that residents are free from significant medication errors. | Health | 2022-11-15 | 2022-06-15 | N |
| Provide and implement an infection prevention and control program. | 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 |
| 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 |
| 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 |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | 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 |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | 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 |
| 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 |
| Ensure each resident receives an accurate assessment. | Health | 2018-11-19 | 2019-01-02 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-11-19 | 2018-11-30 | N |