Deficiency Records for Autumn Lake Healthcare at Birch Manor
Updated as of March 01, 2024
A list of the most recent deficiencies for Autumn Lake Healthcare at Birch Manor. 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? |
|---|---|---|---|---|
| Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Health | 2021-11-23 | 2022-01-07 | Y |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2021-11-23 | 2022-01-07 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-11-23 | 2022-01-07 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-11-23 | 2022-01-07 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-11-23 | 2022-01-07 | Y |
| Observe each nurse aide's job performance and give regular training. | Health | 2021-11-23 | 2022-01-07 | 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 | 2021-11-23 | 2022-01-07 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-11-23 | 2022-01-07 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2021-11-23 | 2022-01-07 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-06-09 | 2021-08-06 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-06-09 | 2021-08-06 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2021-06-09 | 2021-08-06 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2021-06-09 | 2021-08-06 | 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 | 2021-06-09 | 2021-08-06 | 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 | 2021-06-09 | 2021-08-06 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-06-09 | 2021-08-06 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-06-09 | 2021-08-06 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-06-09 | 2021-08-06 | 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 | 2021-06-09 | 2021-08-06 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-06-09 | 2021-08-06 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-06-09 | 2021-08-06 | 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 | 2021-06-09 | 2021-08-06 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-06-09 | 2021-08-06 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-06-09 | 2021-08-06 | 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 | 2021-06-09 | 2021-08-06 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2021-06-09 | 2021-08-06 | N |
| 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 | 2021-06-09 | 2021-08-06 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-06-09 | 2021-08-06 | N |
| Have enough outside ventilation via a window or mechanical ventilation, or both. | Health | 2021-06-09 | 2021-08-06 | N |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2021-06-09 | 2021-08-06 | Y |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2021-06-09 | 2021-08-06 | 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 | 2021-03-04 | 2021-04-15 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-03-04 | 2021-04-15 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-03-04 | 2021-04-15 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-03-04 | 2021-04-15 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2021-03-04 | 2021-04-15 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-03-04 | 2021-04-15 | 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 | 2021-03-04 | 2021-03-04 | Y |
| Address patient/client population and determine types of services needed. | Fire Safety | 2019-12-05 | 2020-03-05 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2019-12-05 | 2020-03-05 | N |
| Establish emergency prep training and testing. | Fire Safety | 2019-12-05 | 2020-03-05 | N |
| Establish staff and initial training requirements. | Fire Safety | 2019-12-05 | 2020-03-05 | 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 | 2019-12-05 | 2020-03-05 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-12-05 | 2020-03-05 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-12-05 | 2020-03-05 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-12-05 | 2020-03-05 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2019-12-05 | 2020-03-05 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-12-05 | 2020-03-05 | N |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2018-08-03 | 2018-10-08 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2018-08-03 | 2018-10-08 | N |
| Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. | Health | 2018-08-03 | 2018-10-08 | N |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2018-08-03 | 2018-10-08 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2018-08-03 | 2018-10-08 | 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 | 2018-08-03 | 2018-10-08 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2018-08-03 | 2018-10-08 | N |
| Respond appropriately to all alleged violations. | Health | 2018-08-03 | 2018-10-08 | 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 | 2018-08-03 | 2018-10-08 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-08-03 | 2018-10-08 | N |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2018-08-03 | 2018-10-08 | 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 | 2018-08-03 | 2018-10-08 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2018-08-03 | 2018-10-08 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-08-03 | 2018-10-08 | N |
| Ensure a qualified health professional conducts resident assessments. | Health | 2018-08-03 | 2018-10-08 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2018-08-03 | 2018-10-08 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-08-03 | 2018-10-08 | 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 | 2018-08-03 | 2018-10-08 | N |
| Provide activities to meet all resident's needs. | Health | 2018-08-03 | 2018-10-08 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-08-03 | 2018-10-08 | 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 | 2018-08-03 | 2018-10-08 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-08-03 | 2018-10-08 | 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 | 2018-08-03 | 2018-10-08 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2018-08-03 | 2018-10-08 | N |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2018-08-03 | 2018-10-08 | N |
| Post nurse staffing information every day. | Health | 2018-08-03 | 2018-10-08 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2018-08-03 | 2018-10-08 | 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 | 2018-08-03 | 2018-10-08 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2018-08-03 | 2018-10-08 | 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 | 2018-08-03 | 2018-10-08 | 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 | 2018-08-03 | 2018-10-08 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2018-08-03 | 2018-10-08 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-08-03 | 2018-10-08 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-08-03 | 2018-10-08 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2018-08-03 | 2018-10-08 | N |
| Implement a program that monitors antibiotic use. | Health | 2018-08-03 | 2018-10-08 | N |
| Keep all essential equipment working safely. | Health | 2018-08-03 | 2018-10-08 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2018-08-03 | 2018-10-08 | 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 | 2018-08-01 | 2018-08-24 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-08-01 | 2018-08-24 | 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 | 2017-06-22 | 2017-09-07 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2017-06-22 | 2017-09-07 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2017-06-22 | 2017-08-22 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2017-06-22 | 2017-08-22 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2017-06-22 | 2017-08-22 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2017-06-22 | 2017-08-22 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2017-04-07 | 2017-06-08 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2017-04-07 | 2017-06-08 | N |
| Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. | Health | 2017-04-07 | 2017-06-08 | N |
| Provide housekeeping and maintenance services. | Health | 2017-04-07 | 2017-06-08 | N |
| Provide clean bed and bath linens that are in good condition. | Health | 2017-04-07 | 2017-06-08 | N |
| Ensure each resident receives an accurate assessment by a qualified health professional. | Health | 2017-04-07 | 2017-06-08 | N |
| Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2017-04-07 | 2017-06-08 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2017-04-07 | 2017-06-08 | N |
| Provide care by qualified persons according to each resident's written plan of care. | Health | 2017-04-07 | 2017-06-08 | N |
| Ensure residents maintain acceptable nutritional status. | Health | 2017-04-07 | 2017-06-08 | 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 | 2017-04-07 | 2017-06-08 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2017-04-07 | 2017-06-08 | 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 | 2017-04-07 | 2017-06-08 | N |
| Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2017-04-07 | 2017-06-08 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2017-04-07 | 2017-06-08 | N |
| Keep all essential equipment working safely. | Health | 2017-04-07 | 2017-06-08 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2017-04-07 | 2017-06-08 | N |
| Have enough backup water supply for essential areas of the nursing home. | Health | 2017-04-07 | 2017-06-08 | N |
| Put firmly secured handrails on each side of hallways. | Health | 2017-04-07 | 2017-06-08 | N |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2017-04-07 | 2017-06-08 | N |
