A list of the most recent deficiencies for Autumn Years Nursing Center. 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 safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2024-01-09 | 2024-01-31 | Y |
| Keep all essential equipment working safely. | Health | 2024-01-09 | 2024-01-31 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-02-28 | 2022-03-30 | 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 | 2022-02-28 | 2022-03-30 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-02-28 | 2022-03-30 | 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 | 2022-02-23 | 2022-03-30 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-02-23 | 2022-03-30 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-02-23 | 2022-03-30 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-02-23 | 2022-03-30 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-07-02 | 2019-09-06 | 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 | 2019-07-02 | 2019-09-06 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-07-02 | 2019-09-06 | N |
| Provide or obtain dental services for each resident. | Health | 2019-07-02 | 2019-09-06 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2019-07-02 | 2019-09-06 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-07-02 | 2019-09-06 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2019-07-02 | 2019-09-06 | 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 | 2019-07-03 | 2019-09-06 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-07-03 | 2019-09-06 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-07-03 | 2019-09-06 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-07-03 | 2019-09-06 | N |
| Ensure operating rooms are properly protected and written records are maintained and available for inspection. | Fire Safety | 2019-07-03 | 2019-09-06 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-05-08 | 2018-06-14 | 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 | 2018-05-08 | 2018-06-14 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-05-08 | 2018-06-14 | 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 | 2018-05-08 | 2018-06-14 | 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 | 2018-05-08 | 2018-06-14 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-05-08 | 2018-06-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-05-08 | 2018-06-14 | N |
| Establish staff and initial training requirements. | Fire Safety | 2018-05-08 | 2018-06-14 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2018-05-08 | 2018-06-14 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-05-08 | 2018-06-14 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2018-05-08 | 2018-06-14 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2018-05-08 | 2018-06-14 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-05-08 | 2018-06-14 | N |
