Deficiency Records for Autumn Lake Healthcare at Perring Parkway
Updated as of April 01, 2024
A list of the most recent deficiencies for Autumn Lake Healthcare at Perring Parkway. 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? |
|---|---|---|---|---|
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-01-11 | 2024-02-19 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2024-01-11 | 2024-02-06 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2024-01-11 | 2024-02-06 | 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 | 2024-01-11 | 2024-02-06 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-01-11 | 2024-02-06 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2024-01-11 | 2024-02-06 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2024-01-11 | 2024-02-06 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-12-22 | 2024-02-02 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-12-22 | 2024-02-02 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-12-22 | 2024-02-02 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-12-22 | 2024-02-02 | 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 | 2023-12-22 | 2024-02-02 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-12-22 | 2024-02-02 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2023-12-22 | 2024-02-02 | N |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2023-12-22 | 2024-02-02 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-12-22 | 2024-02-02 | 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 | 2023-12-22 | 2024-02-02 | 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 | 2023-12-22 | 2024-02-02 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-12-22 | 2024-02-02 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-12-22 | 2024-02-02 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-12-22 | 2024-02-02 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2023-12-22 | 2024-02-02 | 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 | 2021-04-08 | 2021-04-20 | Y |
| Provide properly protected cooking facilities. | Fire Safety | 2019-04-01 | 2019-05-14 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-04-01 | 2019-05-14 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-04-01 | 2019-05-14 | N |
| Provide properly sized and located linen or trash receptacles. | Fire Safety | 2019-04-01 | 2019-05-14 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-04-01 | 2019-05-14 | N |
| Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | Fire Safety | 2019-04-01 | 2019-05-14 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-02-05 | 2019-03-22 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2019-02-05 | 2019-03-22 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-02-05 | 2019-03-22 | 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 | 2019-02-05 | 2019-03-22 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-02-05 | 2019-03-22 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2019-02-05 | 2019-03-22 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-02-05 | 2019-03-22 | 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 | 2019-02-05 | 2019-03-22 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-02-05 | 2019-03-22 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2019-02-05 | 2019-03-22 | 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 | 2019-02-05 | 2019-03-22 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-02-05 | 2019-03-22 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-02-05 | 2019-03-22 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-02-05 | 2019-03-22 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-02-05 | 2019-03-22 | N |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2019-02-05 | 2019-03-22 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2019-02-05 | 2019-03-22 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-02-05 | 2019-03-22 | 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 | 2019-02-05 | 2019-03-22 | N |
| Provide or obtain dental services for each resident. | Health | 2019-02-05 | 2019-03-22 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-02-05 | 2019-03-22 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-02-05 | 2019-03-22 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-02-05 | 2019-03-22 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2019-02-05 | 2019-03-22 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2017-11-30 | 2018-01-09 | N |
| Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. | Health | 2017-10-11 | 2017-12-22 | N |
| Ensure residents have the right to have a choice over activities, their schedules, and health care according to their interests, assessments, and plans of care. | Health | 2017-10-11 | 2017-12-22 | N |
| Ensure each resident receives an accurate assessment by a qualified health professional. | Health | 2017-10-11 | 2017-12-22 | N |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2017-10-11 | 2017-12-22 | N |
| Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene. | Health | 2017-10-11 | 2017-12-22 | N |
| Ensure that residents receive proper treatment and assistive devices to maintain their vision and hearing. | Health | 2017-10-11 | 2017-12-22 | N |
| Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. | Health | 2017-10-11 | 2017-12-22 | N |
| At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor. | Health | 2017-10-11 | 2017-12-22 | N |
| Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2017-10-11 | 2017-12-22 | N |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2017-10-11 | 2017-12-22 | N |
