A list of the most recent deficiencies for Autumn Care of Myrtle Grove. 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 policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-12-01 | 2023-12-21 | Y |
| Meet other general requirements. | Fire Safety | 2023-03-23 | 2023-04-05 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2023-03-23 | 2023-04-05 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-03-23 | 2023-04-05 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-03-23 | 2023-04-05 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-03-23 | 2023-04-05 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-03-02 | 2023-03-21 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-03-02 | 2023-03-21 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-03-02 | 2023-03-21 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-03-02 | 2023-03-21 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-02-09 | 2023-03-21 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-02-09 | 2023-03-21 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-02-09 | 2023-03-09 | 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 | 2023-02-09 | 2023-03-09 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-02-09 | 2023-03-09 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-02-09 | 2023-03-09 | 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 | 2023-02-09 | 2023-03-09 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2023-02-09 | 2023-03-09 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-02-09 | 2023-03-09 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-02-09 | 2023-03-06 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-07-29 | 2022-08-16 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-07-29 | 2022-08-16 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-07-29 | 2022-08-16 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-02-25 | 2022-03-15 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-01-04 | 2022-02-25 | 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 | 2022-01-04 | 2022-02-25 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2022-01-04 | 2022-02-25 | Y |
| Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. | Health | 2022-01-04 | 2022-02-25 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-01-04 | 2022-02-25 | Y |
| 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 | 2022-01-04 | 2022-02-25 | Y |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2022-01-04 | 2022-02-25 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-01-04 | 2022-02-25 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2022-01-04 | 2022-02-25 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-01-04 | 2022-02-25 | Y |
| Address subsistence needs for staff and patients. | Fire Safety | 2022-01-04 | 2022-02-25 | N |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2020-03-05 | 2020-03-16 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2020-03-05 | 2020-03-16 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2020-03-05 | 2020-03-16 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-03-05 | 2020-03-16 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2020-03-05 | 2020-03-16 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2020-03-05 | 2020-03-16 | 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 | 2020-03-05 | 2020-03-16 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-03-05 | 2020-03-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-03-05 | 2020-03-16 | N |
