A list of the most recent deficiencies for Autumn Care of Portsmouth. 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? |
|---|---|---|---|---|
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-04-18 | 2022-06-03 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-04-18 | 2022-06-03 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-04-15 | 2022-05-20 | 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 | 2022-04-15 | 2022-05-20 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-04-15 | 2022-05-20 | 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 | 2022-04-15 | 2022-05-20 | 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 | 2022-04-15 | 2022-05-20 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-04-15 | 2022-05-20 | Y |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2022-04-15 | 2022-05-20 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-04-15 | 2022-05-20 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-04-15 | 2022-05-20 | 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 | 2022-04-15 | 2022-05-20 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-04-15 | 2022-05-20 | Y |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2022-04-15 | 2022-05-20 | Y |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2022-04-15 | 2022-05-20 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2022-04-15 | 2022-05-20 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2022-04-15 | 2022-05-20 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2022-04-15 | 2022-05-20 | N |
| Establish emergency prep training and testing. | Fire Safety | 2022-04-15 | 2022-05-20 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2021-08-12 | 2021-08-27 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-10-09 | 2019-12-04 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-10-09 | 2019-12-04 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-10-09 | 2019-12-04 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-10-09 | 2019-12-04 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2019-10-09 | 2019-12-04 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-10-09 | 2019-12-04 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-10-09 | 2019-12-04 | N |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2019-10-04 | 2019-11-18 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-10-04 | 2019-11-18 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2019-10-04 | 2019-11-18 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2019-10-04 | 2019-11-18 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2019-10-04 | 2019-11-18 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-10-04 | 2019-11-18 | 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 | 2019-10-04 | 2019-11-18 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-10-04 | 2019-11-18 | N |
| Provide appropriate foot care. | Health | 2019-10-04 | 2019-11-18 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-10-04 | 2019-11-18 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2019-10-04 | 2019-11-18 | 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 | 2019-10-04 | 2019-11-18 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-10-04 | 2019-11-18 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2019-10-04 | 2019-11-18 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2019-10-04 | 2019-11-18 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2019-10-04 | 2019-11-18 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2019-10-04 | 2019-11-18 | N |
| Provide emergency officials' contact information. | Fire Safety | 2019-10-04 | 2019-11-18 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-10-04 | 2019-09-04 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2018-05-24 | 2018-07-12 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-05-24 | 2018-07-12 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2018-05-24 | 2018-07-12 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2018-05-24 | 2018-07-12 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2018-05-24 | 2018-07-12 | N |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2018-04-09 | 2018-05-23 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2018-04-09 | 2018-05-23 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-04-09 | 2018-05-23 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2018-04-09 | 2018-05-23 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-04-09 | 2018-05-23 | 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 | 2018-04-09 | 2018-05-23 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-04-09 | 2018-05-23 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2018-04-09 | 2018-05-23 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2018-04-09 | 2018-05-23 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2018-04-09 | 2018-05-23 | 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 | 2018-04-09 | 2018-05-23 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-04-09 | 2018-05-23 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-04-09 | 2018-05-23 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2018-04-09 | 2018-05-23 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2018-04-09 | 2018-05-23 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2018-04-09 | 2018-05-23 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2018-04-09 | 2018-05-23 | N |
| Establish methods for sharing information. | Fire Safety | 2018-04-09 | 2018-05-23 | N |
| Establish emergency prep training and testing. | Fire Safety | 2018-04-09 | 2018-05-23 | N |
| Implement emergency and standby power systems. | Fire Safety | 2018-04-09 | 2018-05-23 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2018-04-09 | 2018-04-09 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2018-04-09 | 2018-04-09 | N |
