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Deficiency Records for Autumn Lake Healthcare at Spa Creek
View the most recent health deficiencies and inspection results for Autumn Lake Healthcare at Spa Creek. Stay informed about quality of care issues.
View the most recent health deficiencies and inspection results for Autumn Lake Healthcare at Spa Creek. Stay informed about quality of care issues.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2025-08-06 | 2025-12-19 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2025-08-06 | 2025-12-19 | 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 | 2025-08-06 | 2025-11-07 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2025-08-06 | 2025-11-07 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2025-08-06 | 2025-11-07 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2025-08-06 | 2025-11-07 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2025-08-06 | 2025-11-07 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2025-08-06 | 2025-11-07 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2025-08-06 | 2025-11-07 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2025-08-06 | 2025-11-07 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2025-08-06 | 2025-11-07 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2025-08-06 | 2025-10-04 | N |
| Honor the resident's right to manage his or her financial affairs. | Health | 2025-08-06 | 2025-10-04 | 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 | 2025-08-06 | 2025-10-04 | N |
| Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. | Health | 2025-08-06 | 2025-10-04 | N |
| Ensure each resident receives an accurate assessment. | Health | 2025-08-06 | 2025-10-04 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2025-08-06 | 2025-10-04 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2025-08-06 | 2025-10-04 | 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 | 2025-08-06 | 2025-10-04 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2025-08-06 | 2025-10-04 | N |
| Ensure the activities program is directed by a qualified professional. | Health | 2025-08-06 | 2025-10-04 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2025-08-06 | 2025-10-04 | 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 | 2025-08-06 | 2025-10-04 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2025-08-06 | 2025-10-04 | 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 | 2025-08-06 | 2025-10-04 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2025-08-06 | 2025-10-04 | N |
| Provide and implement an infection prevention and control program. | Health | 2025-08-06 | 2025-10-04 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2025-08-06 | 2025-10-04 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2025-08-06 | 2025-10-04 | Y |
| Keep all essential equipment working safely. | Health | 2025-08-06 | 2025-10-04 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2025-06-04 | 2025-07-10 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2025-06-04 | 2025-07-10 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2025-06-04 | 2025-07-10 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2025-06-04 | 2025-07-10 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2025-06-04 | 2025-07-10 | Y |
| Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service. | Health | 2025-06-04 | 2025-07-10 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2025-06-04 | 2025-07-10 | Y |
| Provide and implement an infection prevention and control program. | Health | 2025-06-04 | 2025-07-10 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2025-06-04 | 2025-07-10 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2025-06-04 | 2025-07-10 | 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 | 2025-06-04 | 2025-07-10 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-02-03 | 2023-06-02 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-02-03 | 2023-06-02 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2023-02-03 | 2023-05-02 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-02-03 | 2023-05-02 | N |
| Meet other general requirements. | Fire Safety | 2023-02-03 | 2023-05-02 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-02-03 | 2023-05-02 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2023-02-03 | 2023-05-02 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2023-02-03 | 2023-05-02 | N |
| Install proper backup exit lighting. | Fire Safety | 2023-02-03 | 2023-05-02 | 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 | 2023-02-03 | 2023-05-02 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-02-03 | 2023-05-02 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-02-03 | 2023-05-02 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2023-02-03 | 2023-05-02 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-02-03 | 2023-05-02 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-02-03 | 2023-05-02 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-02-03 | 2023-05-02 | N |
| Provide activities to meet all resident's needs. | Health | 2023-02-03 | 2023-04-05 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-02-03 | 2023-04-05 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-02-03 | 2023-04-05 | N |
| Post nurse staffing information every day. | Health | 2023-02-03 | 2023-04-05 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2023-02-03 | 2023-04-05 | 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 | 2023-02-03 | 2023-04-05 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-02-03 | 2023-04-05 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2023-02-03 | 2023-04-05 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-02-03 | 2023-04-05 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-02-03 | 2023-04-05 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2023-02-03 | 2023-04-05 | 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 | 2023-02-03 | 2023-04-05 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-02-03 | 2023-04-05 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-02-03 | 2023-04-05 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-02-03 | 2023-04-05 | 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 | 2023-02-03 | 2023-04-05 | 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 | 2023-02-03 | 2023-04-05 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-02-03 | 2023-04-05 | N |
| Protect each resident from separation (from other residents, his/her room, or confinement to his/her room). | Health | 2023-02-03 | 2023-04-05 | N |
| Respond appropriately to all alleged violations. | Health | 2023-02-03 | 2023-04-05 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2023-02-03 | 2023-04-05 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-02-03 | 2023-04-05 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2018-11-05 | 2018-12-29 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-11-05 | 2018-12-29 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-11-05 | 2018-12-29 | N |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2018-11-05 | 2018-12-29 | N |
| Ensure that residents are free from significant medication errors. | Health | 2018-11-05 | 2018-12-29 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2018-11-05 | 2018-12-29 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2018-11-05 | 2018-12-29 | 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 | 2018-11-05 | 2018-12-29 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-11-05 | 2018-12-29 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2018-11-05 | 2018-12-29 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2018-11-05 | 2018-12-29 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-11-05 | 2018-12-29 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-11-05 | 2018-12-29 | 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 | 2018-11-05 | 2018-12-29 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-11-05 | 2018-12-29 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2018-11-05 | 2018-12-29 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-11-05 | 2018-12-29 | 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 | 2018-11-05 | 2018-12-29 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-11-05 | 2018-12-29 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2018-11-05 | 2018-12-29 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2018-11-05 | 2018-12-29 | N |