Deficiency Records for Autumn Care of Norfolk
Updated as of September 01, 2018
This is not the most recent data for Autumn Care of Norfolk. For the most recent information, click here.
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? |
|---|---|---|---|---|
| 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 |
| 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 |
| 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 |
| 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, 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 |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2018-02-14 | 2018-03-30 | Y |
| Give residents a notice of rights, rules, services and charges. | Health | 2016-10-14 | 2016-11-18 | N |
| 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. | Health | 2016-10-14 | 2016-11-18 | N |
| Provide housekeeping and maintenance services. | Health | 2016-10-14 | 2016-11-18 | N |
| Allow residents the right to participate in the planning or revision of care and treatment. | Health | 2016-10-14 | 2016-11-18 | N |
| Give proper treatment to residents with feeding tubes to prevent problems (such as aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, nasal-pharyngeal ulcers) and help restore eating skills, if possible. | Health | 2016-10-14 | 2016-11-18 | N |
| Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. | Health | 2016-10-14 | 2016-11-18 | N |
| Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2016-10-14 | 2016-11-18 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2016-10-14 | 2016-11-18 | N |
| Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2015-09-08 | 2015-11-10 | N |
| Give residents a notice of rights, rules, services and charges. | Health | 2015-09-08 | 2015-10-22 | N |
| Allow residents to self-administer drugs if determined safe. | Health | 2015-09-08 | 2015-10-22 | N |
| Allow residents the right to participate in the planning or revision of care and treatment. | Health | 2015-09-08 | 2015-10-22 | N |
| Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. | Health | 2015-09-08 | 2015-10-22 | N |
| Post nurse staffing information/data on a daily basis. | Health | 2015-09-08 | 2015-10-22 | N |
| Protect each resident from mistreatment, neglect and misappropriation of personal property. | Health | 2015-09-08 | 2015-10-22 | Y |
| Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. | Health | 2015-09-08 | 2015-10-22 | Y |
| Ensure each resident receives an accurate assessment by a qualified health professional. | Health | 2015-09-08 | 2015-10-22 | Y |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2015-09-08 | 2015-10-22 | Y |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2015-09-08 | 2015-10-22 | Y |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2015-09-08 | 2015-10-22 | Y |
| Train all employees on what to do in an emergency, and carry out unannounced staff drills. | Health | 2015-09-08 | 2015-10-22 | Y |
