Deficiency Records for Autumn Years Nursing Center
Updated as of November 01, 2020
This is not the most recent data for Autumn Years Nursing Center. For the most recent information, click here.
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? |
|---|---|---|---|---|
| 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 | 2019-10-21 | 2019-11-04 | Y |
| 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 |
| Provide and implement an infection prevention and control program. | Health | 2019-08-14 | 2019-09-06 | Y |
| 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 |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-04-04 | 2019-04-26 | Y |
| Give residents a notice of rights, rules, services and charges. | Health | 2019-04-04 | 2019-04-26 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-04-04 | 2019-04-26 | 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 | 2019-04-04 | 2019-04-26 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-04-04 | 2019-04-26 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2019-04-04 | 2019-04-26 | 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 | 2019-01-30 | 2019-02-18 | Y |
| 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 |
| 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 |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2018-02-06 | 2018-02-07 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2018-02-06 | 2018-02-07 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-01-09 | 2018-02-07 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2017-03-30 | 2017-06-30 | N |
| Have exits that are accessible at all times. | Fire Safety | 2017-03-30 | 2017-06-05 | 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 | 2017-03-30 | 2017-06-05 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2017-03-30 | 2017-06-05 | N |
| Have an alternate power supply for its alarm system. | Fire Safety | 2017-03-30 | 2017-06-05 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2017-03-30 | 2017-06-05 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2017-03-30 | 2017-06-05 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2017-03-30 | 2017-06-05 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2017-03-31 | 2017-06-05 | N |
| Keep each resident free from physical restraints, unless needed for medical treatment. | Health | 2017-03-31 | 2017-06-05 | N |
| Provide a safe, clean, comfortable and home-like environment; and allow residents to use personal belongings to the extent possible. | Health | 2017-03-31 | 2017-06-05 | N |
| Provide housekeeping and maintenance services. | Health | 2017-03-31 | 2017-06-05 | N |
| Ensure each resident receives an accurate assessment by a qualified health professional. | Health | 2017-03-31 | 2017-06-05 | N |
| Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2017-03-31 | 2017-06-05 | N |
| Allow residents the right to participate in the planning or revision of care and treatment. | Health | 2017-03-31 | 2017-06-05 | N |
| Provide care by qualified persons according to each resident's written plan of care. | Health | 2017-03-31 | 2017-06-05 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2017-03-31 | 2017-06-05 | N |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2017-03-31 | 2017-06-05 | N |
| Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. | Health | 2017-03-31 | 2017-06-05 | N |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2017-03-31 | 2017-06-05 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2017-03-31 | 2017-06-05 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2017-03-31 | 2017-06-05 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2017-03-31 | 2017-06-05 | N |
| Put firmly secured handrails on each side of hallways. | Health | 2017-03-31 | 2017-06-05 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2017-03-31 | 2017-06-05 | N |
| Keep clinical record information safe. | Health | 2017-03-31 | 2017-06-05 | N |
| Give residents a notice of rights, rules, services and charges. | Health | 2017-03-31 | 2017-05-13 | N |
| Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. | Health | 2017-03-31 | 2017-05-13 | N |
| Post nurse staffing information/data on a daily basis. | Health | 2017-03-31 | 2017-05-13 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action. | Health | 2017-03-31 | 2017-05-13 | N |
