Deficiency Records for Autumn Lake Healthcare at Summit Park
Updated as of April 01, 2024
A list of the most recent deficiencies for Autumn Lake Healthcare at Summit Park. 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? |
|---|---|---|---|---|
| Conduct testing and exercise requirements. | Fire Safety | 2023-12-12 | 2024-03-05 | 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 | 2023-12-12 | 2024-03-05 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-12-12 | 2024-03-05 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2023-12-12 | 2024-03-05 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-12-22 | 2024-02-06 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2023-12-22 | 2024-02-06 | 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 | 2023-12-22 | 2024-02-06 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2023-12-22 | 2024-02-06 | 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 | 2023-12-22 | 2024-02-06 | N |
| Respond appropriately to all alleged violations. | Health | 2023-12-22 | 2024-02-06 | N |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2023-12-22 | 2024-02-06 | 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 | 2023-12-22 | 2024-02-06 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-12-22 | 2024-02-06 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-12-22 | 2024-02-06 | 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 | 2023-12-22 | 2024-02-06 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-12-22 | 2024-02-06 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-12-22 | 2024-02-06 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-12-22 | 2024-02-06 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-12-22 | 2024-02-06 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-12-22 | 2024-02-06 | N |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2023-12-22 | 2024-02-06 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-12-22 | 2024-02-06 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-12-22 | 2024-02-06 | 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 | 2023-12-22 | 2024-02-06 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-12-22 | 2024-02-06 | 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 | 2023-12-22 | 2024-02-06 | N |
| Provide or obtain dental services for each resident. | Health | 2023-12-22 | 2024-02-06 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2023-12-22 | 2024-02-06 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2023-12-22 | 2024-02-06 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-12-22 | 2024-02-06 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2023-12-22 | 2024-02-06 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-12-22 | 2024-02-06 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2023-12-22 | 2024-02-06 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-12-22 | 2024-02-06 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2023-12-22 | 2024-02-06 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-12-22 | 2024-02-06 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-12-12 | 2024-02-01 | N |
| Meet other general requirements. | Fire Safety | 2023-12-12 | 2024-02-01 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-12-12 | 2024-02-01 | 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 | 2023-12-12 | 2024-02-01 | N |
| Install proper backup exit lighting. | Fire Safety | 2023-12-12 | 2024-02-01 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-12-12 | 2024-02-01 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-12-12 | 2024-02-01 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-12-12 | 2024-02-01 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-12-12 | 2024-02-01 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2023-12-12 | 2024-02-01 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-12-12 | 2024-02-01 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-12-12 | 2024-02-01 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-12-12 | 2024-02-01 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-12-12 | 2024-02-01 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-11-13 | 2023-12-20 | Y |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2023-11-13 | 2023-12-20 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2019-03-21 | 2019-07-30 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-03-21 | 2019-07-30 | 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 | 2019-03-21 | 2019-07-30 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-03-21 | 2019-07-30 | 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 | 2019-03-21 | 2019-07-30 | 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 | 2019-03-21 | 2019-07-30 | 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 | 2019-05-02 | 2019-06-14 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2019-05-02 | 2019-06-14 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-05-02 | 2019-06-14 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-05-02 | 2019-06-14 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-03-21 | 2019-05-21 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-03-21 | 2019-05-21 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2019-03-21 | 2019-05-21 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2019-03-21 | 2019-05-21 | 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 | 2019-03-21 | 2019-05-21 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2019-03-21 | 2019-05-21 | N |
| Ensure that each resident is free from medications that restrain them, unless needed for medical treatment. | Health | 2019-03-21 | 2019-05-21 | N |
| Respond appropriately to all alleged violations. | Health | 2019-03-21 | 2019-05-21 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-03-21 | 2019-05-21 | 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 | 2019-03-21 | 2019-05-21 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-03-21 | 2019-05-21 | N |
| Provide activities to meet all resident's needs. | Health | 2019-03-21 | 2019-05-21 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2019-03-21 | 2019-05-21 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-03-21 | 2019-05-21 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-03-21 | 2019-05-21 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-03-21 | 2019-05-21 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2019-03-21 | 2019-05-21 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-03-21 | 2019-05-21 | 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 | 2019-03-21 | 2019-05-21 | N |
| Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them. | Health | 2019-03-21 | 2019-05-21 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-03-21 | 2019-05-21 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2019-03-21 | 2019-05-21 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-03-21 | 2019-05-21 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2017-10-23 | 2018-01-19 | N |
| Ensure each resident receives an accurate assessment by a qualified health professional. | Health | 2017-10-23 | 2018-01-19 | N |
| Allow residents the right to participate in the planning or revision of care and treatment. | Health | 2017-10-23 | 2018-01-19 | N |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2017-10-23 | 2018-01-19 | N |
| Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%. | Health | 2017-10-23 | 2018-01-19 | N |
| Have enough nurses to care for every resident in a way that maximizes the resident's well being. | Health | 2017-10-23 | 2018-01-19 | N |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2017-10-23 | 2018-01-19 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action. | Health | 2017-10-23 | 2018-01-19 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2017-12-12 | 2018-01-08 | 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 | 2017-12-12 | 2018-01-08 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2017-12-12 | 2018-01-08 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2017-12-12 | 2018-01-08 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2017-12-12 | 2018-01-08 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2017-12-12 | 2018-01-08 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2017-12-12 | 2018-01-08 | N |
| Protect each resident from all abuse, physical punishment, and involuntary separation from others. | Health | 2017-10-23 | 2017-12-08 | N |
| 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. | Health | 2017-10-23 | 2017-12-08 | N |
| Provide housekeeping and maintenance services. | Health | 2017-10-23 | 2017-12-08 | N |
| Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene. | Health | 2017-10-23 | 2017-12-08 | N |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2017-10-23 | 2017-12-08 | 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 | 2017-10-23 | 2017-12-08 | N |
