A list of the most recent deficiencies for Autumn Care of Biscoe. 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? |
|---|---|---|---|---|
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-12-08 | 2022-12-30 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-12-08 | 2022-12-30 | 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 | 2022-10-31 | 2022-11-15 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-10-31 | 2022-11-15 | 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 | 2022-10-31 | 2022-11-15 | 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 | 2022-10-31 | 2022-11-15 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2022-10-31 | 2022-11-15 | 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 | 2022-10-31 | 2022-11-15 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-10-31 | 2022-11-15 | 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 | 2022-10-31 | 2022-11-15 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-10-31 | 2022-11-15 | 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 | 2022-10-31 | 2022-11-15 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-10-31 | 2022-11-15 | Y |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-11-16 | 2021-12-10 | N |
| Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. | Health | 2021-10-21 | 2021-11-12 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-10-21 | 2021-11-12 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-10-21 | 2021-11-12 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-10-21 | 2021-11-12 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-10-21 | 2021-11-12 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-10-21 | 2021-11-12 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2021-10-21 | 2021-11-12 | 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 | 2021-10-21 | 2021-11-12 | 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 | 2021-10-21 | 2021-11-12 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-10-21 | 2021-11-12 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-05-21 | 2021-05-24 | Y |
| Install proper backup exit lighting. | Fire Safety | 2019-07-11 | 2019-08-23 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-07-11 | 2019-08-23 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-07-11 | 2019-08-23 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-07-11 | 2019-08-23 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-06-13 | 2019-07-03 | 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 | 2019-06-13 | 2019-07-03 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-06-13 | 2019-07-03 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2019-06-13 | 2019-07-03 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-06-13 | 2019-07-03 | 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 | 2019-06-13 | 2019-07-03 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-06-13 | 2019-07-03 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2019-06-13 | 2019-07-03 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2019-06-13 | 2019-07-03 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2019-06-13 | 2019-07-03 | N |
