Deficiency Records for Autumn Lake Healthcare at Birch Manor
Updated as of May 01, 2019
This is not the most recent data for Autumn Lake Healthcare at Birch Manor. For the most recent information, click here.
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? |
---|---|---|---|---|
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 ne | 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 |
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2018-04-20 | 2018-06-27 | Y |
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2018-04-20 | 2018-06-27 | Y |
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 | 2018-04-20 | 2018-06-27 | Y |
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2018-01-19 | 2018-02-12 | Y |
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2018-01-19 | 2018-02-12 | 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 | 2017-11-21 | 2017-12-13 | Y |
Establish and follow a written policy that permits a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2017-08-10 | 2017-09-08 | Y |
Protect each resident from mistreatment, neglect and misappropriation of personal property. | Health | 2017-08-10 | 2017-09-08 | Y |
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 other general requirements that are deficient. | 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 |
Have a program that investigates, controls and keeps infection from spreading. | Health | 2017-04-07 | 2017-06-08 | N |
Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2017-04-07 | 2017-06-08 | Y |
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 | Y |
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 | Y |
Provide housekeeping and maintenance services. | Health | 2017-04-07 | 2017-06-08 | Y |
Provide clean bed and bath linens that are in good condition. | Health | 2017-04-07 | 2017-06-08 | Y |
Ensure each resident receives an accurate assessment by a qualified health professional. | Health | 2017-04-07 | 2017-06-08 | Y |
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 | Y |
Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2017-04-07 | 2017-06-08 | Y |
Provide care by qualified persons according to each resident's written plan of care. | Health | 2017-04-07 | 2017-06-08 | Y |
Ensure residents maintain acceptable nutritional status. | Health | 2017-04-07 | 2017-06-08 | Y |
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 | Y |
Store, cook, and serve food in a safe and clean way. | Health | 2017-04-07 | 2017-06-08 | Y |
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 | Y |
Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2017-04-07 | 2017-06-08 | Y |
Keep all essential equipment working safely. | Health | 2017-04-07 | 2017-06-08 | Y |
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 | Y |
Have enough backup water supply for essential areas of the nursing home. | Health | 2017-04-07 | 2017-06-08 | Y |
Put firmly secured handrails on each side of hallways. | Health | 2017-04-07 | 2017-06-08 | Y |
Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2017-04-07 | 2017-06-08 | Y |
Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2017-04-07 | 2017-06-08 | Y |
Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action. | Health | 2017-04-07 | 2017-06-08 | Y |
1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. | Health | 2016-12-16 | 2017-01-12 | Y |
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2016-11-15 | 2016-12-05 | Y |
Upon the death of a resident, convey the resident?s personal funds and an accounting of those funds to the appropriate party. | Health | 2016-11-15 | 2016-12-05 | Y |
Exits that are accessible at all times. | Fire Safety | 2016-06-10 | 2016-09-01 | N |
Provide housekeeping and maintenance services. | Health | 2016-06-09 | 2016-08-07 | N |
Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2016-06-09 | 2016-08-07 | Y |
Give residents a notice of rights, rules, services and charges. | Health | 2016-06-09 | 2016-08-07 | Y |
Ensure each resident receives an accurate assessment by a qualified health professional. | Health | 2016-06-09 | 2016-08-07 | Y |
Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2016-06-09 | 2016-08-07 | Y |
Allow residents the right to participate in the planning or revision of care and treatment. | Health | 2016-06-09 | 2016-08-07 | Y |
Provide care by qualified persons according to each resident's written plan of care. | Health | 2016-06-09 | 2016-08-07 | Y |
Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2016-06-09 | 2016-08-07 | Y |
Ensure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions. | Health | 2016-06-09 | 2016-08-07 | Y |
Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2016-06-09 | 2016-08-07 | Y |
Store, cook, and serve food in a safe and clean way. | Health | 2016-06-09 | 2016-08-07 | Y |
At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor. | Health | 2016-06-09 | 2016-08-07 | Y |
Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2016-06-09 | 2016-08-07 | Y |
Keep all essential equipment working safely. | Health | 2016-06-09 | 2016-08-07 | Y |
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2016-06-09 | 2016-08-07 | Y |
Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2016-06-09 | 2016-08-07 | Y |
Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action. | Health | 2016-06-09 | 2016-08-07 | Y |
Fire resistant room wall surfaces. | Fire Safety | 2016-06-10 | 2016-08-01 | N |
Special areas constructed so that walls can resist fire for one hour or an approved fire extinguishing system. | Fire Safety | 2016-06-10 | 2016-08-01 | N |
Portable fire extinguishers. | Fire Safety | 2016-06-10 | 2016-08-01 | N |
Weekly inspections and monthly testing of generators. | Fire Safety | 2016-06-10 | 2016-08-01 | N |
Properly installed electrical wiring and equipment. | Fire Safety | 2016-06-10 | 2016-08-01 | N |