Deficiency Records for Autumn Lake Healthcare at Braddock Heights
Updated as of April 01, 2024
A list of the most recent deficiencies for Autumn Lake Healthcare at Braddock Heights. 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? |
|---|---|---|---|---|
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-10-25 | 2021-12-03 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-10-25 | 2021-12-03 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-10-25 | 2021-12-03 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-06-27 | 2019-08-07 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2019-06-27 | 2019-08-07 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2019-06-27 | 2019-08-07 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-06-27 | 2019-08-07 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2019-06-27 | 2019-08-07 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-06-27 | 2019-08-07 | N |
| Respond appropriately to all alleged violations. | Health | 2019-06-27 | 2019-08-07 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-06-27 | 2019-08-07 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-06-27 | 2019-08-07 | 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 | 2019-06-27 | 2019-08-07 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-06-27 | 2019-08-07 | 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 | 2019-06-27 | 2019-08-07 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-06-27 | 2019-08-07 | 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 | 2019-06-27 | 2019-08-07 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-06-27 | 2019-08-07 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2019-06-27 | 2019-08-07 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-02-27 | 2018-04-09 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2018-02-27 | 2018-04-09 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2018-02-27 | 2018-04-09 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2018-02-27 | 2018-04-09 | 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 | 2018-02-27 | 2018-04-09 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2018-02-27 | 2018-04-09 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2018-02-27 | 2018-04-09 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-02-27 | 2018-04-09 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-02-27 | 2018-04-09 | 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 | 2018-02-27 | 2018-04-09 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2018-02-27 | 2018-04-09 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-02-27 | 2018-04-09 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-02-27 | 2018-04-09 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2018-02-27 | 2018-04-09 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2018-02-27 | 2018-04-09 | N |
| Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. | Health | 2018-02-27 | 2018-04-09 | N |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2018-02-27 | 2018-04-09 | 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 | 2018-02-27 | 2018-04-09 | 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 | 2018-02-27 | 2018-04-09 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2018-02-27 | 2018-04-09 | N |
| Ensure that residents are free from significant medication errors. | Health | 2018-02-27 | 2018-04-09 | 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 | 2018-02-27 | 2018-04-09 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2018-02-27 | 2018-04-09 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2018-02-27 | 2018-04-09 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-02-27 | 2018-04-09 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-02-27 | 2018-04-09 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2018-02-27 | 2018-04-09 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-02-27 | 2018-04-09 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2018-02-27 | 2018-04-09 | N |
| Keep all essential equipment working safely. | Health | 2018-02-27 | 2018-04-09 | N |
| Have enough backup water supply for essential areas of the nursing home. | Health | 2018-02-27 | 2018-04-09 | 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 | 2018-02-26 | 2018-03-24 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2018-02-26 | 2018-03-24 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-02-26 | 2018-03-24 | 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 | 2016-12-02 | 2016-12-27 | N |
| Provide housekeeping and maintenance services. | Health | 2016-12-02 | 2016-12-27 | N |
| Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2016-12-02 | 2016-12-27 | N |
| 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 | 2016-12-02 | 2016-12-27 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2016-12-02 | 2016-12-27 | 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 | 2016-12-02 | 2016-12-27 | N |
| Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2016-12-02 | 2016-12-27 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2016-12-02 | 2016-12-27 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action. | Health | 2016-12-02 | 2016-12-27 | N |
