Deficiency Records for Autumn Lake Healthcare at Glade Valley
Updated as of March 01, 2024
A list of the most recent deficiencies for Autumn Lake Healthcare at Glade Valley. 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? |
|---|---|---|---|---|
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2023-11-15 | 2024-02-06 | Y |
| Ensure the activities program is directed by a qualified professional. | Health | 2023-11-15 | 2024-02-06 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-11-15 | 2024-02-06 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-11-15 | 2024-02-06 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-10-15 | 2021-11-19 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-10-15 | 2021-11-19 | N |
| Provide activities to meet all resident's needs. | Health | 2021-10-15 | 2021-11-19 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-10-15 | 2021-11-19 | N |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2021-10-15 | 2021-11-19 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2021-10-15 | 2021-11-19 | N |
| Post nurse staffing information every day. | Health | 2021-10-15 | 2021-11-19 | N |
| Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. | Health | 2021-10-15 | 2021-11-19 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-10-15 | 2021-11-19 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-10-15 | 2021-11-19 | 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 | 2021-10-15 | 2021-11-19 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-10-15 | 2021-11-19 | 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 | 2021-10-15 | 2021-11-19 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2021-10-15 | 2021-11-19 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-10-15 | 2021-11-19 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2021-10-15 | 2021-11-19 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2021-10-15 | 2021-11-19 | 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 | 2021-10-15 | 2021-11-19 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2021-10-15 | 2021-11-19 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-10-15 | 2021-11-19 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-10-15 | 2021-11-19 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-10-15 | 2021-11-19 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2021-10-15 | 2021-11-19 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-10-15 | 2021-11-19 | 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 | 2021-10-15 | 2021-11-19 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-10-15 | 2021-11-19 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-10-15 | 2021-11-19 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-10-15 | 2021-11-19 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-10-19 | 2021-11-19 | N |
| Establish staff and initial training requirements. | Fire Safety | 2021-10-19 | 2021-11-19 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-10-19 | 2021-11-19 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-10-19 | 2021-11-19 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-10-19 | 2021-11-19 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-10-19 | 2021-11-19 | 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 | 2018-09-18 | 2018-10-26 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-09-18 | 2018-10-26 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-09-18 | 2018-10-26 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-09-18 | 2018-10-26 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2018-09-18 | 2018-10-26 | 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 | 2018-09-18 | 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 | 2018-09-18 | 2018-10-26 | 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 | 2018-09-18 | 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 | 2018-09-18 | 2018-10-26 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-09-18 | 2018-10-26 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-09-18 | 2018-10-26 | N |
| Keep all essential equipment working safely. | Health | 2018-09-18 | 2018-10-26 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2017-06-20 | 2017-08-01 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2017-06-20 | 2017-08-01 | N |
| Listen to the resident groups and act on their complaints and suggestions that affect resident care and life. | Health | 2017-06-16 | 2017-07-31 | N |
| Provide housekeeping and maintenance services. | Health | 2017-06-16 | 2017-07-31 | N |
| Ensure each resident receives an accurate assessment by a qualified health professional. | Health | 2017-06-16 | 2017-07-31 | N |
| Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2017-06-16 | 2017-07-31 | N |
| Provide care by qualified persons according to each resident's written plan of care. | Health | 2017-06-16 | 2017-07-31 | N |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2017-06-16 | 2017-07-31 | 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 | 2017-06-16 | 2017-07-31 | N |
| Have enough nurses to care for every resident in a way that maximizes the resident's well being. | Health | 2017-06-16 | 2017-07-31 | N |
| Post nurse staffing information/data on a daily basis. | Health | 2017-06-16 | 2017-07-31 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2017-06-16 | 2017-07-31 | N |
| Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2017-06-16 | 2017-07-31 | N |
| Keep all essential equipment working safely. | Health | 2017-06-16 | 2017-07-31 | N |
