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Deficiency Records for Autumn Lake Healthcare at Alice Manor
View the most recent health deficiencies and inspection results for Autumn Lake Healthcare at Alice Manor. Stay informed about quality of care issues.
View the most recent health deficiencies and inspection results for Autumn Lake Healthcare at Alice Manor. Stay informed about quality of care issues.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Use approved construction type or materials. | Fire Safety | 2025-05-01 | 2025-09-03 | N |
| Have correct number of accessible exits for each story. | Fire Safety | 2025-05-01 | 2025-09-03 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2025-05-01 | 2025-07-11 | N |
| Establish an Emergency Preparedness Program (EP). | Fire Safety | 2025-05-01 | 2025-07-11 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2025-05-01 | 2025-07-11 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2025-05-01 | 2025-07-11 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2025-05-01 | 2025-07-11 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2025-05-01 | 2025-07-11 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2025-05-01 | 2025-07-11 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2025-05-01 | 2025-07-11 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2025-05-01 | 2025-07-11 | 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 | 2025-05-01 | 2025-07-11 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2025-05-01 | 2025-07-11 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2025-05-01 | 2025-07-11 | 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 | 2025-05-01 | 2025-06-06 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2025-05-01 | 2025-06-06 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2025-05-01 | 2025-06-06 | N |
| Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training. | Health | 2025-05-01 | 2025-06-06 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2025-05-01 | 2025-06-06 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2025-05-01 | 2025-06-06 | N |
| Provide or obtain dental services for each resident. | Health | 2025-05-01 | 2025-06-06 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2025-05-01 | 2025-06-06 | N |
| Provide and implement an infection prevention and control program. | Health | 2025-05-01 | 2025-06-06 | 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 | 2025-05-01 | 2025-06-06 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2025-05-01 | 2025-06-06 | Y |
| 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 | 2025-05-01 | 2025-06-06 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-11-20 | 2025-01-28 | 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 | 2024-11-20 | 2025-01-28 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-11-20 | 2025-01-28 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-11-20 | 2025-01-28 | Y |
| Respond appropriately to all alleged violations. | Health | 2024-11-20 | 2025-01-28 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2024-11-20 | 2025-01-28 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2024-11-20 | 2025-01-28 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-11-20 | 2025-01-28 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-11-20 | 2025-01-28 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-11-20 | 2025-01-28 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. | Health | 2024-11-20 | 2025-01-28 | Y |
| 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 | 2024-11-20 | 2025-01-28 | Y |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2024-11-20 | 2025-01-28 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2024-11-20 | 2024-03-15 | Y |
| Use approved construction type or materials. | Fire Safety | 2021-06-14 | 2022-06-03 | N |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2021-06-14 | 2021-08-13 | N |
| 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 | 2021-06-14 | 2021-08-13 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-06-14 | 2021-08-13 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-06-14 | 2021-08-13 | 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 | 2021-06-14 | 2021-08-13 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-06-14 | 2021-08-13 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2021-06-14 | 2021-08-13 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-06-14 | 2021-08-13 | 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 | 2021-06-14 | 2021-08-13 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-06-14 | 2021-08-13 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-06-14 | 2021-08-13 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-06-14 | 2021-08-13 | 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 | 2021-06-14 | 2021-08-13 | N |
| Post nurse staffing information every day. | Health | 2021-06-14 | 2021-08-13 | 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 | 2021-06-14 | 2021-08-13 | 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 | 2021-06-14 | 2021-08-13 | N |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2021-06-14 | 2021-08-13 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-06-14 | 2021-08-13 | 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 | 2021-06-14 | 2021-08-13 | N |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2021-06-14 | 2021-08-13 | N |
| Put firmly secured handrails on each side of hallways. | Health | 2021-06-14 | 2021-08-13 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-06-14 | 2021-08-13 | 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 | 2021-06-14 | 2021-08-13 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2021-06-14 | 2021-07-25 | N |
| Ensure equipment listed for use in oxygen-enriched atmospheres are correctly labeled. | Fire Safety | 2021-06-14 | 2021-07-25 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-06-14 | 2021-07-25 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-06-14 | 2021-07-25 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-06-14 | 2021-07-25 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2021-06-14 | 2021-07-25 | N |
| Provide rooms that can be unlocked from inside without a key. | Fire Safety | 2021-06-14 | 2021-07-25 | N |
| Establish staff and initial training requirements. | Fire Safety | 2021-06-14 | 2021-07-25 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2021-06-14 | 2021-07-25 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-09-12 | 2018-10-26 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2018-09-12 | 2018-10-26 | 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 | 2018-09-12 | 2018-10-26 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-09-12 | 2018-10-26 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-09-12 | 2018-10-26 | N |
| Use approved construction type or materials. | Fire Safety | 2018-09-12 | 2018-10-09 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2018-09-12 | 2018-10-09 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2018-09-12 | 2018-10-09 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2018-09-12 | 2018-10-09 | N |
| Install proper backup exit lighting. | Fire Safety | 2018-09-12 | 2018-10-09 | N |
| Have correct number of accessible exits for each story. | Fire Safety | 2018-09-12 | 2018-10-09 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2018-09-12 | 2018-10-09 | 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 | 2026-04-17 | Not Fixed | Y |