A list of the most recent deficiencies for Autumn Lake Healthcare at Arcola. 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? |
|---|---|---|---|---|
| Keep residents' personal and medical records private and confidential. | Health | 2019-08-28 | 2019-11-21 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2019-08-28 | 2019-11-21 | N |
| Respond appropriately to all alleged violations. | Health | 2019-08-28 | 2019-11-21 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-08-28 | 2019-11-21 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2019-08-28 | 2019-11-21 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2019-08-28 | 2019-11-21 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-08-28 | 2019-10-25 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-08-28 | 2019-10-25 | 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 | 2019-08-28 | 2019-10-25 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2019-08-28 | 2019-10-25 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-08-28 | 2019-10-25 | N |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2019-08-28 | 2019-10-25 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-08-28 | 2019-10-25 | 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 | 2019-08-28 | 2019-10-25 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2019-08-28 | 2019-10-25 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2019-08-28 | 2019-10-25 | 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 | 2019-08-28 | 2019-10-25 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-08-28 | 2019-10-25 | N |
| Hire a qualified full-time social worker in a facility with more than 120 beds. | Health | 2019-08-28 | 2019-10-25 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2019-08-28 | 2019-10-25 | N |
| Construct fire resistant interior walls. | Fire Safety | 2019-07-23 | 2019-08-31 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-07-23 | 2019-08-31 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2019-07-23 | 2019-08-31 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2019-07-23 | 2019-08-31 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-07-23 | 2019-08-31 | 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 | 2018-08-31 | 2018-11-06 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2018-08-31 | 2018-11-06 | 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 | 2018-08-31 | 2018-11-06 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2018-08-31 | 2018-11-06 | N |
| Respond appropriately to all alleged violations. | Health | 2018-08-31 | 2018-11-06 | 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 | 2018-08-31 | 2018-11-06 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-08-31 | 2018-11-06 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-08-31 | 2018-11-06 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-08-31 | 2018-11-06 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2018-08-31 | 2018-11-06 | N |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2018-08-31 | 2018-11-06 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2018-08-31 | 2018-11-06 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2018-08-31 | 2018-11-06 | N |
| Meet other general requirements. | Fire Safety | 2018-09-06 | 2018-10-25 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2018-09-06 | 2018-10-25 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-09-06 | 2018-10-25 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-09-06 | 2018-10-25 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2018-09-06 | 2018-10-25 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-09-06 | 2018-10-25 | N |
| Provide housekeeping and maintenance services. | Health | 2017-09-01 | 2017-10-13 | N |
| Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2017-09-01 | 2017-10-13 | N |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2017-09-01 | 2017-10-13 | N |
| Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. | Health | 2017-09-01 | 2017-10-13 | N |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2017-09-01 | 2017-10-13 | N |
| Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%. | Health | 2017-09-01 | 2017-10-13 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2017-09-01 | 2017-10-13 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2017-09-01 | 2017-10-13 | N |
| Keep all essential equipment working safely. | Health | 2017-09-01 | 2017-10-13 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2017-09-01 | 2017-10-13 | 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 | 2017-09-05 | 2017-09-29 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2017-09-05 | 2017-09-29 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2017-09-05 | 2017-09-29 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2017-09-05 | 2017-09-29 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2017-09-05 | 2017-09-29 | N |
