A list of the most recent deficiencies for Autumn Lake Healthcare at Oakview. 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 request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2023-11-03 | 2024-01-04 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-11-03 | 2024-01-04 | 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 | 2023-11-03 | 2024-01-04 | 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 | 2023-11-03 | 2024-01-04 | N |
| Assess the resident when there is a significant change in condition | Health | 2023-11-03 | 2024-01-04 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-11-03 | 2024-01-04 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-11-03 | 2024-01-04 | N |
| Provide activities to meet all resident's needs. | Health | 2023-11-03 | 2024-01-04 | 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 | 2023-11-03 | 2024-01-04 | 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 | 2023-11-03 | 2024-01-04 | 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 | 2023-11-03 | 2024-01-04 | 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 | 2023-11-03 | 2024-01-04 | 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 | 2023-11-03 | 2024-01-04 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-11-03 | 2024-01-04 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-11-03 | 2024-01-04 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-11-03 | 2024-01-04 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-11-03 | 2024-01-04 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2023-11-03 | 2024-01-04 | 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 | 2023-11-03 | 2024-01-04 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-11-03 | 2024-01-04 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-11-03 | 2024-01-04 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-11-03 | 2024-01-04 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-11-03 | 2024-01-04 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-11-03 | 2024-01-04 | 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 | 2023-11-03 | 2024-01-04 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-11-03 | 2024-01-04 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-11-03 | 2024-01-04 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-11-03 | 2024-01-04 | Y |
| 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 | 2023-11-03 | 2024-01-04 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-11-03 | 2024-01-04 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-11-08 | 2023-12-08 | N |
| Meet other general requirements. | Fire Safety | 2023-11-08 | 2023-12-08 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-11-08 | 2023-12-08 | 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 | 2023-11-08 | 2023-12-08 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-11-08 | 2023-12-08 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-11-08 | 2023-12-08 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-11-08 | 2023-12-08 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-11-08 | 2023-12-08 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-11-08 | 2023-12-08 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-11-08 | 2023-12-08 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-11-08 | 2023-12-08 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-04-09 | 2021-05-21 | 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 | 2019-10-25 | 2019-12-25 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2019-10-25 | 2019-12-25 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-10-25 | 2019-12-25 | 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 | 2019-10-25 | 2019-12-25 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-10-25 | 2019-12-25 | 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 | 2019-10-25 | 2019-12-25 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-10-25 | 2019-12-25 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-10-25 | 2019-12-25 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-10-25 | 2019-12-25 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-10-25 | 2019-12-25 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2019-10-25 | 2019-12-25 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2019-10-25 | 2019-12-25 | 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 | 2019-10-25 | 2019-12-25 | 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 | 2019-10-25 | 2019-12-25 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-10-25 | 2019-12-25 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-10-25 | 2019-12-25 | N |
| Have policies on smoking. | Health | 2019-10-25 | 2019-12-25 | N |
| Meet other general requirements. | Fire Safety | 2019-10-23 | 2019-12-18 | 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 | 2019-10-23 | 2019-12-18 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2019-10-23 | 2019-12-18 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-10-23 | 2019-12-18 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-02-05 | 2019-04-03 | 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 | 2019-02-05 | 2019-04-03 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2019-02-05 | 2019-04-03 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-02-05 | 2019-04-03 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-02-05 | 2019-04-03 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2019-02-05 | 2019-04-03 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2019-02-05 | 2019-04-03 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2019-02-05 | 2019-04-03 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-02-05 | 2019-04-03 | 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 | 2018-11-13 | 2018-12-14 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-11-13 | 2018-12-14 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2018-11-13 | 2018-12-14 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2018-11-13 | 2018-12-14 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-11-13 | 2018-12-14 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-11-13 | 2018-12-14 | 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 | 2018-11-13 | 2018-12-14 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2018-11-13 | 2018-12-14 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-11-13 | 2018-12-14 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-11-13 | 2018-12-14 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2018-11-13 | 2018-12-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-11-13 | 2018-12-14 | N |
