Deficiency Records for Autumn Lake Healthcare at Cherry Lane
Updated as of April 01, 2024
A list of the most recent deficiencies for Autumn Lake Healthcare at Cherry Lane. 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? |
|---|---|---|---|---|
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2023-08-04 | 2023-10-13 | Y |
| 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 | 2023-08-04 | 2023-10-13 | Y |
| Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. | Health | 2023-08-04 | 2023-10-13 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-08-04 | 2023-10-13 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-08-04 | 2023-10-13 | 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 | 2023-08-04 | 2023-10-13 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2023-08-04 | 2023-10-13 | 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 | 2023-08-04 | 2023-10-13 | N |
| 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 | 2023-08-04 | 2023-10-13 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-08-04 | 2023-10-13 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-08-04 | 2023-10-13 | 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 | 2023-08-04 | 2023-10-13 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-08-04 | 2023-10-13 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-08-04 | 2023-10-13 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-08-04 | 2023-10-13 | N |
| Implement a program that monitors antibiotic use. | Health | 2023-08-04 | 2023-10-13 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2023-08-04 | 2023-10-13 | N |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2023-08-04 | 2023-10-13 | N |
| Respond appropriately to all alleged violations. | Health | 2023-08-04 | 2023-10-13 | Y |
| 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 | 2023-08-04 | 2023-10-13 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-08-04 | 2023-10-13 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-08-04 | 2023-10-13 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-08-04 | 2023-10-13 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-08-04 | 2023-10-13 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-08-04 | 2023-10-13 | Y |
| Enure that solid fuel-burning fireplaces are not in patient sleeping areas. | Fire Safety | 2023-07-18 | 2023-10-02 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-07-18 | 2023-10-02 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-07-18 | 2023-10-02 | N |
| Meet other general requirements. | Fire Safety | 2023-07-18 | 2023-07-31 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-07-18 | 2023-07-31 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2023-07-18 | 2023-07-31 | 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 | 2023-07-18 | 2023-07-31 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-07-18 | 2023-07-31 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-07-18 | 2023-07-31 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-07-18 | 2023-07-31 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-07-18 | 2023-07-31 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-07-18 | 2023-07-31 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-07-18 | 2023-07-31 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-07-18 | 2023-07-31 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-03-08 | 2022-04-22 | Y |
| 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 | 2019-01-28 | 2019-04-08 | N |
| Assess the resident when there is a significant change in condition | Health | 2019-01-28 | 2019-04-08 | 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 | 2019-01-28 | 2019-04-08 | 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 | 2019-01-28 | 2019-04-08 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-01-31 | 2019-02-04 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-01-31 | 2019-02-04 | N |
| Have an externally vented heating system. | Fire Safety | 2019-01-31 | 2019-02-04 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2019-01-31 | 2019-02-04 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-01-31 | 2019-02-04 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-01-31 | 2019-02-04 | N |
| Give residents a notice of rights, rules, services and charges. | Health | 2017-09-28 | 2017-11-03 | N |
| Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2017-09-28 | 2017-11-03 | N |
| Post nurse staffing information/data on a daily basis. | Health | 2017-09-28 | 2017-11-03 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2017-09-28 | 2017-11-03 | N |
| Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2017-09-28 | 2017-11-03 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2017-09-28 | 2017-11-03 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2017-09-28 | 2017-11-03 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2017-09-28 | 2017-11-03 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2017-09-28 | 2017-11-03 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2017-09-28 | 2017-11-03 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2017-09-28 | 2017-11-03 | N |
