A list of the most recent deficiencies for Autumn Care of Norfolk. 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? |
|---|---|---|---|---|
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2023-01-13 | 2023-02-13 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-01-13 | 2023-02-13 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-01-13 | 2023-02-13 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-01-13 | 2023-02-13 | N |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2023-01-13 | 2023-02-13 | N |
| Report COVID19 data to residents and families. | Health | 2023-01-13 | 2023-02-13 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-01-13 | 2023-02-13 | Y |
| Provide appropriate foot care. | Health | 2023-01-13 | 2023-02-13 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-01-13 | 2023-02-13 | 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 | 2023-01-13 | 2023-02-13 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-01-13 | 2023-02-13 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-02-11 | 2022-03-04 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-09-26 | 2019-11-14 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-09-26 | 2019-11-14 | N |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2019-09-20 | 2019-10-18 | N |
| Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. | Health | 2019-09-20 | 2019-10-18 | 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 | 2019-09-20 | 2019-10-18 | 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 | 2019-09-20 | 2019-10-18 | 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 | 2019-09-20 | 2019-10-18 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-09-20 | 2019-10-18 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-09-20 | 2019-10-18 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-09-20 | 2019-10-18 | 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 | 2019-09-20 | 2019-10-18 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-09-20 | 2019-10-18 | N |
| Provide activities to meet all resident's needs. | Health | 2019-09-20 | 2019-10-18 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-09-20 | 2019-10-18 | 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 | 2019-09-20 | 2019-10-18 | 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 | 2019-09-20 | 2019-10-18 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-09-20 | 2019-10-18 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2019-09-20 | 2019-10-18 | N |
| Establish emergency prep training and testing. | Fire Safety | 2019-09-20 | 2019-10-18 | N |
| Establish staff and initial training requirements. | Fire Safety | 2019-09-20 | 2019-10-18 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-09-20 | 2019-04-17 | 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 | 2018-03-06 | 2018-06-01 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2018-03-06 | 2018-06-01 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-03-06 | 2018-06-01 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2018-03-06 | 2018-06-01 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-03-06 | 2018-06-01 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2018-03-06 | 2018-05-21 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-03-06 | 2018-05-21 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2018-03-06 | 2018-05-21 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2018-02-14 | 2018-03-30 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2018-02-14 | 2018-03-30 | 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 | 2018-02-14 | 2018-03-30 | N |
| Ensure a qualified health professional conducts resident assessments. | Health | 2018-02-14 | 2018-03-30 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2018-02-14 | 2018-03-30 | 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 | 2018-02-14 | 2018-03-30 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-02-14 | 2018-03-30 | 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 | 2018-02-14 | 2018-03-30 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2018-02-14 | 2018-03-30 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2018-02-14 | 2018-03-30 | 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 | 2018-02-14 | 2018-03-30 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-02-14 | 2018-03-30 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-02-14 | 2018-03-30 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2018-02-14 | 2018-03-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-02-14 | 2018-03-30 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2018-02-14 | 2018-03-30 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2018-02-14 | 2018-03-30 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2018-02-14 | 2018-03-30 | N |
| Establish staff and initial training requirements. | Fire Safety | 2018-02-14 | 2018-03-30 | N |
