A list of the most recent deficiencies for Autumn Lake Healthcare at Voorhees. 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? |
|---|---|---|---|---|
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-11-19 | 2022-01-18 | 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 | 2021-11-19 | 2022-01-18 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-11-19 | 2022-01-18 | Y |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-09-17 | 2021-11-10 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2021-09-17 | 2021-10-28 | 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 | 2021-09-17 | 2021-10-19 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-09-17 | 2021-10-19 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2021-09-17 | 2021-10-19 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-09-17 | 2021-10-19 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-09-17 | 2021-10-19 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-09-17 | 2021-10-18 | N |
| Respond appropriately to all alleged violations. | Health | 2021-09-17 | 2021-10-18 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-09-17 | 2021-10-18 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-09-17 | 2021-10-18 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2021-09-17 | 2021-10-18 | N |
| Ensure that residents are free from significant medication errors. | Health | 2021-06-04 | 2021-07-04 | Y |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2019-09-27 | 2019-11-08 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-09-27 | 2019-11-08 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-09-27 | 2019-11-08 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-09-27 | 2019-11-08 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-09-27 | 2019-11-08 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-09-27 | 2019-11-08 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-09-27 | 2019-11-08 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-08-28 | 2018-10-19 | N |
| 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 | 2018-08-28 | 2018-10-19 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2018-08-28 | 2018-10-19 | 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 | 2018-08-28 | 2018-10-19 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-08-28 | 2018-10-19 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-08-28 | 2018-10-19 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2018-08-28 | 2018-10-19 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2018-08-28 | 2018-10-19 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-08-28 | 2018-10-19 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-08-28 | 2018-10-19 | N |
