Deficiency Records for Autumn Lake Healthcare at Alice Manor
Updated as of March 01, 2024
A list of the most recent deficiencies for Autumn Lake Healthcare at Alice Manor. 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? |
|---|---|---|---|---|
| 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 |
| 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 |
| PASARR screening for Mental disorders or Intellectual Disabilities | 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 |
| 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 |
| Provide and implement an infection prevention and control program. | 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 |
| 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 | Y |
| 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 | Y |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2021-06-14 | 2021-08-13 | 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 | 2021-06-14 | 2021-08-13 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2021-06-14 | 2021-08-13 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-06-14 | 2021-08-13 | 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 | 2021-06-14 | 2021-08-13 | Y |
| Post nurse staffing information every day. | Health | 2021-06-14 | 2021-08-13 | Y |
| 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 | Y |
| 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 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-06-14 | 2021-08-13 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-06-14 | 2021-08-13 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-06-14 | 2021-08-13 | Y |
| 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 | 2018-09-10 | 2018-10-09 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2018-09-10 | 2018-10-09 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2018-09-10 | 2018-10-09 | N |
| Have correct number of accessible exits for each story. | Fire Safety | 2018-09-10 | 2018-10-09 | N |
| Install proper backup exit lighting. | Fire Safety | 2018-09-10 | 2018-10-09 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2018-09-10 | 2018-10-09 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2018-09-10 | 2018-10-09 | N |
| 1) Review the work of each nurse aide every year; and 2) give regular in-service training based upon these reviews. | Health | 2017-05-10 | 2017-06-23 | N |
| Make sure that nurse aides show they have the skills and techniques to be able to care for residents' needs. | Health | 2017-05-10 | 2017-06-23 | N |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2017-05-10 | 2017-06-23 | N |
| Train all employees on what to do in an emergency, and carry out unannounced staff drills. | Health | 2017-05-10 | 2017-06-23 | N |
