Deficiency Records for Autumn Lake Healthcare at Waugh Chapel
Updated as of March 01, 2024
A list of the most recent deficiencies for Autumn Lake Healthcare at Waugh Chapel. 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? |
|---|---|---|---|---|
| Respond appropriately to all alleged violations. | Health | 2021-08-13 | 2021-09-20 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-08-13 | 2021-09-20 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-08-13 | 2021-09-20 | Y |
| Provide rooms that can be unlocked from inside without a key. | Fire Safety | 2020-01-30 | 2020-08-27 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2020-01-30 | 2020-08-27 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-01-30 | 2020-08-27 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2020-01-30 | 2020-08-27 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2020-01-30 | 2020-08-27 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2020-02-03 | 2020-03-07 | N |
| Respond appropriately to all alleged violations. | Health | 2020-02-03 | 2020-03-07 | N |
| Ensure each resident receives an accurate assessment. | Health | 2020-02-03 | 2020-03-07 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-02-03 | 2020-03-07 | 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 | 2020-02-03 | 2020-03-07 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2020-02-03 | 2020-03-07 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2020-02-03 | 2020-03-07 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2020-02-03 | 2020-03-07 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-02-03 | 2020-03-07 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2020-02-03 | 2020-03-07 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-02-03 | 2020-03-07 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-08-01 | 2018-09-13 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-08-01 | 2018-09-13 | N |
| Provide appropriate foot care. | Health | 2018-08-01 | 2018-09-13 | 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 | 2018-08-01 | 2018-09-13 | N |
| Keep all essential equipment working safely. | Health | 2018-08-01 | 2018-09-13 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2017-04-28 | 2017-07-06 | N |
| Ensure each resident receives an accurate assessment by a qualified health professional. | Health | 2017-04-28 | 2017-07-06 | N |
| Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2017-04-28 | 2017-07-06 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2017-04-28 | 2017-07-06 | N |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2017-04-28 | 2017-07-06 | N |
| Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%. | Health | 2017-04-28 | 2017-07-06 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2017-04-28 | 2017-07-06 | 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 | 2017-04-28 | 2017-07-06 | N |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2017-04-28 | 2017-07-06 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action. | Health | 2017-04-28 | 2017-07-06 | N |
