A list of the most recent deficiencies for Autumn Lake Healthcare at Spa Creek. 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? |
|---|---|---|---|---|
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-03-02 | 2023-06-02 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-03-02 | 2023-06-02 | N |
| Meet other general requirements. | Fire Safety | 2023-03-02 | 2023-05-02 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-03-02 | 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 | 2023-03-02 | 2023-05-02 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2023-03-02 | 2023-05-02 | N |
| Install proper backup exit lighting. | Fire Safety | 2023-03-02 | 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 | 2023-03-02 | 2023-05-02 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-03-02 | 2023-05-02 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-03-02 | 2023-05-02 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2023-03-02 | 2023-05-02 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-03-02 | 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 | 2023-03-02 | 2023-05-02 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-03-02 | 2023-05-02 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2023-03-02 | 2023-05-02 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-03-02 | 2023-05-02 | N |
| Reasonably accommodate the needs and preferences of each resident. | 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 |
| Ensure each resident receives an accurate assessment. | 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 |
| 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 |
| 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 |
| 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 | Y |
| 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 | 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 | 2023-02-03 | 2023-04-05 | Y |
| Protect each resident from separation (from other residents, his/her room, or confinement to his/her room). | Health | 2023-02-03 | 2023-04-05 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-02-03 | 2023-04-05 | Y |
| 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 | Y |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2023-02-03 | 2023-04-05 | 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 | 2023-02-03 | 2023-04-05 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-02-03 | 2023-04-05 | Y |
| Post nurse staffing information every day. | Health | 2023-02-03 | 2023-04-05 | Y |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2023-02-03 | 2023-04-05 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-02-03 | 2023-04-05 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-02-03 | 2023-04-05 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-02-03 | 2023-04-05 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2021-11-23 | 2022-04-30 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-11-23 | 2022-04-30 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-11-23 | 2022-04-30 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-11-23 | 2022-04-30 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-11-23 | 2022-04-30 | Y |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | 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 |
| 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 |
| 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 |
| Ensure each resident receives an accurate assessment. | 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 |
| 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 |
| 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 |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | 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 enough food/fluids to maintain a resident's health. | 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 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 |
| 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 |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | 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 that residents are free from significant medication errors. | 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 |
| 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 |
| 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 |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2018-11-05 | 2018-12-29 | N |
| Have exits that are accessible at all times. | Fire Safety | 2017-07-14 | 2017-08-31 | 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 | 2017-07-14 | 2017-08-31 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2017-07-14 | 2017-08-31 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2017-07-14 | 2017-08-31 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2017-07-14 | 2017-08-31 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2017-07-14 | 2017-08-31 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2017-07-14 | 2017-08-31 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2017-07-14 | 2017-08-31 | N |
| Try to resolve each resident's complaints quickly. | Health | 2017-07-13 | 2017-08-27 | N |
| Review or revise the resident's care plan after any major change in physical or mental health. | Health | 2017-07-13 | 2017-08-27 | 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 | 2017-07-13 | 2017-08-27 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2017-07-13 | 2017-08-27 | N |
| Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2017-07-13 | 2017-08-27 | N |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2017-07-13 | 2017-08-27 | N |
