Deficiency Records for Autumn Lake Healthcare at Bradford Oaks
Updated as of March 01, 2024
A list of the most recent deficiencies for Autumn Lake Healthcare at Bradford Oaks. 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? |
|---|---|---|---|---|
| Ensure each resident receives an accurate assessment. | Health | 2021-08-25 | 2021-10-11 | 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 | 2021-08-25 | 2021-10-11 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2021-08-25 | 2021-10-11 | Y |
| Post nurse staffing information every day. | Health | 2021-08-25 | 2021-10-11 | Y |
| 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 | 2021-08-25 | 2021-10-11 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-08-25 | 2021-10-11 | Y |
| Report COVID19 data to residents and families. | Health | 2021-08-25 | 2021-10-11 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-12-10 | 2020-02-17 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-12-10 | 2020-01-22 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-12-10 | 2020-01-22 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-12-10 | 2020-01-22 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-12-10 | 2020-01-22 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-12-17 | 2020-01-13 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-12-17 | 2020-01-13 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-12-17 | 2020-01-13 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-12-17 | 2020-01-13 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2019-12-17 | 2020-01-13 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-12-17 | 2020-01-13 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-07-11 | 2018-08-25 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2018-07-11 | 2018-08-25 | 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 | 2018-07-11 | 2018-08-25 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2018-07-11 | 2018-08-25 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2018-07-11 | 2018-08-25 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-07-11 | 2018-08-25 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-07-11 | 2018-08-25 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-07-11 | 2018-08-25 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2018-07-11 | 2018-08-25 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-07-11 | 2018-08-25 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-07-11 | 2018-08-25 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-07-11 | 2018-08-25 | N |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2018-07-11 | 2018-08-25 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2018-07-11 | 2018-08-25 | N |
| Provide housekeeping and maintenance services. | Health | 2017-03-30 | 2017-05-14 | N |
| Conduct initial and periodic assessments of each resident's functional capacity. | Health | 2017-03-30 | 2017-05-14 | N |
| Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2017-03-30 | 2017-05-14 | N |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2017-03-30 | 2017-05-14 | N |
| Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. | Health | 2017-03-30 | 2017-05-14 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2017-03-30 | 2017-05-14 | N |
| Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2017-03-30 | 2017-05-14 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2017-03-30 | 2017-05-14 | N |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2017-03-30 | 2017-05-14 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2017-03-20 | 2017-05-08 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2017-03-20 | 2017-05-08 | N |
