Deficiency Records for Autumn Lake Healthcare at Arlington West
Updated as of March 01, 2024
A list of the most recent deficiencies for Autumn Lake Healthcare at Arlington West. 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 dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-05-06 | 2022-07-05 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2022-05-06 | 2022-07-05 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-05-06 | 2022-07-05 | N |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2022-05-06 | 2022-07-05 | 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 | 2022-05-06 | 2022-07-05 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-05-06 | 2022-07-05 | N |
| Post nurse staffing information every day. | Health | 2022-05-06 | 2022-07-05 | 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 | 2022-05-06 | 2022-07-05 | 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 | 2022-05-06 | 2022-07-05 | N |
| Provide or obtain dental services for each resident. | Health | 2022-05-06 | 2022-07-05 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-05-06 | 2022-07-05 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-05-06 | 2022-07-05 | N |
| Report COVID19 data to residents and families. | Health | 2022-05-06 | 2022-07-05 | N |
| Perform COVID19 testing on residents and staff. | Health | 2022-05-06 | 2022-07-05 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2022-05-06 | 2022-07-05 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-05-06 | 2022-07-05 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-05-06 | 2022-07-05 | Y |
| 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 | 2022-05-06 | 2022-07-05 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-05-06 | 2022-07-05 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-05-06 | 2022-07-05 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-05-06 | 2022-07-05 | 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 | 2022-05-06 | 2022-07-05 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-05-06 | 2022-07-05 | Y |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2022-05-06 | 2022-07-05 | Y |
| 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 | 2022-05-06 | 2022-07-05 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-05-06 | 2022-07-05 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-05-06 | 2022-07-05 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-05-06 | 2022-07-05 | Y |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2022-05-10 | 2022-06-17 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2022-05-10 | 2022-06-17 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-05-10 | 2022-06-17 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-05-10 | 2022-06-17 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-05-10 | 2022-06-17 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-05-10 | 2022-06-17 | N |
| Meet other general requirements. | Fire Safety | 2021-05-05 | 2021-06-25 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2018-11-01 | 2018-12-08 | N |
| Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. | Health | 2018-11-01 | 2018-12-08 | 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 | 2018-11-01 | 2018-12-08 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2018-11-01 | 2018-12-08 | N |
| Respond appropriately to all alleged violations. | Health | 2018-11-01 | 2018-12-08 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-11-01 | 2018-12-08 | 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 | 2018-11-01 | 2018-12-08 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-11-01 | 2018-12-08 | 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 | 2018-11-01 | 2018-12-08 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-11-01 | 2018-12-08 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-11-01 | 2018-12-08 | 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 | 2018-11-01 | 2018-12-08 | N |
| Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. | Health | 2017-07-27 | 2017-09-08 | N |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2017-07-27 | 2017-09-08 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2017-07-27 | 2017-09-08 | N |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2017-07-27 | 2017-09-08 | N |
