A list of the most recent deficiencies for Autumn Lake Healthcare at Oak 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? |
|---|---|---|---|---|
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-04-01 | 2021-05-28 | Y |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2021-04-01 | 2021-05-28 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2020-10-20 | 2020-12-04 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2020-10-20 | 2020-12-04 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2020-10-20 | 2020-12-04 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-10-20 | 2020-12-04 | 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 | 2020-10-20 | 2020-12-04 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2020-10-20 | 2020-12-04 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2020-10-20 | 2020-12-04 | 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 | 2020-10-20 | 2020-12-04 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-10-20 | 2020-12-04 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-10-20 | 2020-12-04 | N |
| Meet other general requirements. | Fire Safety | 2020-10-22 | 2020-12-04 | 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 | 2020-10-22 | 2020-12-04 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2020-10-22 | 2020-12-04 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2020-10-22 | 2020-12-04 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2019-01-22 | 2019-03-08 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-01-22 | 2019-03-08 | 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 | 2019-01-22 | 2019-03-08 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-01-22 | 2019-03-08 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-01-22 | 2019-03-08 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-01-22 | 2019-03-08 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2019-01-22 | 2019-03-08 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-01-22 | 2019-03-08 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2019-01-22 | 2019-03-08 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-01-22 | 2019-03-08 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2019-01-22 | 2019-03-08 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-01-22 | 2019-03-08 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2019-01-22 | 2019-03-08 | 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 | 2019-01-25 | 2019-03-08 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-01-25 | 2019-03-08 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2019-01-25 | 2019-03-08 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2019-01-25 | 2019-03-08 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-01-25 | 2019-03-08 | N |
| Meet other general requirements. | Fire Safety | 2018-02-01 | 2018-03-19 | 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 | 2018-02-01 | 2018-03-19 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2018-02-01 | 2018-03-19 | 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 | 2018-02-01 | 2018-03-19 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-02-01 | 2018-03-19 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-02-01 | 2018-03-19 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2018-02-01 | 2018-03-19 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-02-01 | 2018-03-19 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-01-22 | 2018-03-08 | N |
| Give the resident's representative the ability to exercise the resident's rights. | Health | 2018-01-22 | 2018-03-08 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2018-01-22 | 2018-03-08 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2018-01-22 | 2018-03-08 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-01-22 | 2018-03-08 | 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 | 2018-01-22 | 2018-03-08 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2018-01-22 | 2018-03-08 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-01-22 | 2018-03-08 | 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 | 2018-01-22 | 2018-03-08 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2018-01-22 | 2018-03-08 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-01-22 | 2018-03-08 | N |
