Deficiency Records for Autumn Lake Healthcare Post-Acute Care Center
Updated as of March 01, 2024
A list of the most recent deficiencies for Autumn Lake Healthcare Post-Acute Care Center. 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? |
|---|---|---|---|---|
| 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 | 2023-03-21 | 2023-07-05 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-03-21 | 2023-07-05 | 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 | 2023-03-21 | 2023-07-05 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2023-03-21 | 2023-07-05 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-03-21 | 2023-05-22 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-03-21 | 2023-05-22 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-03-21 | 2023-05-22 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-03-21 | 2023-05-22 | 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 | 2023-03-21 | 2023-05-22 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-03-21 | 2023-05-22 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-03-21 | 2023-05-22 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-03-21 | 2023-05-22 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-03-21 | 2023-05-22 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-03-21 | 2023-05-22 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-03-21 | 2023-05-22 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-03-21 | 2023-05-22 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-03-21 | 2023-05-22 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-03-21 | 2023-05-22 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-21 | 2023-05-22 | Y |
| Meet other general requirements. | Fire Safety | 2023-03-17 | 2023-05-03 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-03-17 | 2023-05-03 | 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 | 2023-03-17 | 2023-05-03 | 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 | 2023-03-17 | 2023-05-03 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2023-03-17 | 2023-05-03 | N |
| Have exits that are accessible at all times. | Fire Safety | 2023-03-17 | 2023-05-03 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-03-17 | 2023-05-03 | 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 | 2023-03-17 | 2023-05-03 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-03-17 | 2023-05-03 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-03-17 | 2023-05-03 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-03-17 | 2023-05-03 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-03-17 | 2023-05-03 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2023-03-17 | 2023-05-03 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-03-17 | 2023-05-03 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-03-17 | 2023-05-03 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-03-17 | 2023-05-03 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-03-17 | 2023-05-03 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-03-17 | 2023-05-03 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-03-17 | 2023-05-03 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-03-17 | 2023-05-03 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-03-21 | 2022-06-22 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-01-26 | 2022-03-26 | Y |
| Not hire anyone with a finding of abuse, neglect, exploitation, or theft. | Health | 2022-01-26 | 2022-03-26 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-01-26 | 2022-03-26 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-01-26 | 2022-03-26 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-01-26 | 2022-03-26 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-01-26 | 2022-03-26 | Y |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2022-01-26 | 2022-03-26 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-05-25 | 2021-07-23 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-05-25 | 2021-07-23 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-05-25 | 2021-07-23 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-05-25 | 2021-07-23 | Y |
| 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 | 2019-05-28 | 2019-07-05 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-05-28 | 2019-07-05 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2019-05-28 | 2019-07-05 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-05-28 | 2019-07-05 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-04-09 | 2019-06-13 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-04-09 | 2019-06-13 | 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 | 2019-04-09 | 2019-06-13 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2019-04-09 | 2019-06-13 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-04-09 | 2019-06-13 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-04-09 | 2019-06-13 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-04-09 | 2019-06-13 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2019-04-09 | 2019-06-13 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2019-04-09 | 2019-06-13 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-03-05 | 2018-04-24 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-03-05 | 2018-04-24 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-03-05 | 2018-04-19 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2018-03-05 | 2018-03-30 | N |
| Meet Health Care Facilities Code mechanical requirements. | Fire Safety | 2018-03-05 | 2018-03-19 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-03-05 | 2018-03-13 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2018-03-05 | 2018-03-05 | N |
| Provide resident groups or resident family groups with private space to meet. | Health | 2017-11-10 | 2017-12-11 | 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 | 2017-11-10 | 2017-12-11 | N |
| Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2017-11-10 | 2017-12-11 | N |
