Deficiency Records for Autumn Lake Healthcare at Bridgepark
Updated as of March 01, 2024
A list of the most recent deficiencies for Autumn Lake Healthcare at Bridgepark. 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 residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2021-11-10 | 2021-12-16 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-11-10 | 2021-12-16 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2021-11-10 | 2021-12-16 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2021-11-10 | 2021-12-16 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-11-10 | 2021-12-16 | 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 | 2021-11-10 | 2021-12-16 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-11-10 | 2021-12-16 | 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 | 2021-11-10 | 2021-12-16 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-11-10 | 2021-12-16 | N |
| Provide activities to meet all resident's needs. | Health | 2021-11-10 | 2021-12-16 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-11-10 | 2021-12-16 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-11-10 | 2021-12-16 | N |
| Provide appropriate foot care. | Health | 2021-11-10 | 2021-12-16 | 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 | 2021-11-10 | 2021-12-16 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-11-10 | 2021-12-16 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-11-10 | 2021-12-16 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-11-10 | 2021-12-16 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-11-10 | 2021-12-16 | N |
| Post nurse staffing information every day. | Health | 2021-11-10 | 2021-12-16 | 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 | 2021-11-10 | 2021-12-16 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-11-10 | 2021-12-16 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-11-10 | 2021-12-16 | 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 | 2021-11-10 | 2021-12-16 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2021-11-10 | 2021-12-16 | N |
| Provide or obtain dental services for each resident. | Health | 2021-11-10 | 2021-12-16 | 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 | 2021-11-10 | 2021-12-16 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-11-10 | 2021-12-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-11-10 | 2021-12-16 | N |
| Keep all essential equipment working safely. | Health | 2021-11-10 | 2021-12-16 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-11-10 | 2021-12-16 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-11-10 | 2021-12-16 | Y |
| Install properly constructed windows in hallway walls or doors. | Fire Safety | 2021-11-16 | 2021-12-16 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-11-16 | 2021-12-16 | N |
| Ensure gas and vacuum systems are inspected and tested as part of a maintenance program. | Fire Safety | 2021-11-16 | 2021-12-16 | N |
| Provide rooms that can be unlocked from inside without a key. | Fire Safety | 2021-06-30 | 2021-10-07 | Y |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-06-30 | 2021-10-07 | Y |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-06-30 | 2021-10-07 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-06-30 | 2021-08-14 | Y |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2021-06-30 | 2021-08-14 | Y |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2021-06-30 | 2021-08-14 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-06-30 | 2021-08-14 | Y |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-06-30 | 2021-08-14 | Y |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-06-30 | 2021-08-14 | Y |
| Ensure equipment listed for use in oxygen-enriched atmospheres are correctly labeled. | Fire Safety | 2021-06-30 | 2021-08-14 | Y |
| Honor each resident's preferences, choices, values and beliefs. | Health | 2021-03-01 | 2021-03-22 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-03-01 | 2021-03-22 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-12-17 | 2019-03-15 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2018-12-17 | 2019-01-24 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2018-12-17 | 2019-01-24 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-12-17 | 2019-01-24 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2018-12-17 | 2019-01-24 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2018-12-17 | 2019-01-24 | N |
| Provide properly sized and located linen or trash receptacles. | Fire Safety | 2018-12-17 | 2019-01-24 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2018-11-29 | 2019-01-14 | N |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2018-11-29 | 2019-01-14 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2018-11-29 | 2019-01-14 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-11-29 | 2019-01-14 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-11-29 | 2019-01-14 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-11-29 | 2019-01-14 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2018-11-29 | 2019-01-14 | 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 | 2018-11-29 | 2019-01-14 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2018-11-29 | 2019-01-14 | 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 | 2018-11-29 | 2019-01-14 | 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 | 2018-11-29 | 2019-01-14 | N |
| Provide or obtain dental services for each resident. | Health | 2018-11-29 | 2019-01-14 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-11-29 | 2019-01-14 | N |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2018-11-29 | 2019-01-14 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-11-29 | 2019-01-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-11-29 | 2019-01-14 | N |
| Keep all essential equipment working safely. | Health | 2018-11-29 | 2019-01-14 | N |
| Have policies on smoking. | Health | 2018-11-29 | 2019-01-14 | N |
| 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 | 2017-08-14 | 2017-09-15 | N |
| Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. | Health | 2017-08-14 | 2017-09-15 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2017-08-14 | 2017-09-15 | N |
| Provide housekeeping and maintenance services. | Health | 2017-08-14 | 2017-09-15 | N |
| Ensure each resident receives an accurate assessment by a qualified health professional. | Health | 2017-08-14 | 2017-09-15 | N |
| Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene. | Health | 2017-08-14 | 2017-09-15 | N |
| 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 | 2017-08-14 | 2017-09-15 | N |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2017-08-14 | 2017-09-15 | N |
| Ensure residents maintain acceptable nutritional status. | Health | 2017-08-14 | 2017-09-15 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2017-08-14 | 2017-09-15 | N |
| Make sure that a doctor approves a resident's admission in writing and that each resident remains under the care of a doctor. | Health | 2017-08-14 | 2017-09-15 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2017-08-14 | 2017-09-15 | N |
| Operate and provide services according to Federal, State, and local laws and professional standards. | Health | 2017-08-14 | 2017-09-15 | N |
| Give or get quality laboratory services/tests in a timely manner to meet the needs of residents. | Health | 2017-08-14 | 2017-09-15 | N |
| Ensure laboratory services, blood blanks and transfusion services provided on site meet requirements for certified laboratories; or have an agreement to obtain services from an offsite laboratory, that meets the same requirements. | Health | 2017-08-14 | 2017-09-15 | N |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2017-08-14 | 2017-09-15 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action. | Health | 2017-08-14 | 2017-09-15 | N |
