A list of the most recent deficiencies for Autumn Lake Healthcare at Southgate. 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? |
|---|---|---|---|---|
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2023-01-17 | 2023-02-08 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-01-17 | 2023-02-08 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-01-17 | 2023-02-08 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2023-01-17 | 2023-02-08 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-01-17 | 2023-02-06 | 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 | 2023-01-17 | 2023-01-24 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-01-17 | 2023-01-24 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2023-01-17 | 2023-01-24 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-01-17 | 2023-01-24 | N |
| Post nurse staffing information every day. | Health | 2023-01-17 | 2023-01-24 | 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 | 2023-01-17 | 2023-01-24 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-01-17 | 2023-01-24 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2021-06-21 | 2021-07-09 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-06-21 | 2021-06-29 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-06-21 | 2021-06-29 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-10-21 | 2020-11-04 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2019-05-15 | 2019-05-22 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-05-15 | 2019-05-22 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-05-15 | 2019-05-22 | N |
