Deficiency Records for Autumn Winds Living and Rehabilitation
Updated as of March 01, 2024
A list of the most recent deficiencies for Autumn Winds Living and Rehabilitation. 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 | 2023-10-18 | 2023-11-06 | 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 | 2023-10-18 | 2023-11-06 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-10-18 | 2023-11-06 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-10-18 | 2023-11-06 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-10-18 | 2023-11-06 | N |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2023-10-18 | 2023-11-06 | Y |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2023-10-18 | 2023-11-06 | Y |
| 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 | 2023-10-18 | 2023-11-06 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2023-10-18 | 2023-11-06 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-10-18 | 2023-11-06 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-10-18 | 2023-11-06 | 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 | 2023-10-18 | 2023-11-06 | Y |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-10-17 | 2023-10-30 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-10-17 | 2023-10-30 | N |
| Ensure precautions for handling oxygen cylinders and equipment are correctly followed. | Fire Safety | 2023-10-17 | 2023-10-30 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-10-17 | 2023-10-18 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-10-17 | 2023-10-18 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-05-01 | 2023-05-02 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-05-01 | 2023-05-02 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-05-01 | 2023-05-02 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-03-31 | 2023-04-24 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-03-31 | 2023-04-14 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-03-31 | 2023-04-14 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-03-31 | 2023-04-14 | Y |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2022-08-31 | 2022-10-20 | N |
| Have an alternate power supply for its alarm system. | Fire Safety | 2022-08-31 | 2022-10-20 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-08-31 | 2022-10-20 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-08-31 | 2022-10-20 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-08-19 | 2022-09-09 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2022-08-19 | 2022-09-09 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-08-19 | 2022-09-09 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-08-19 | 2022-09-09 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-08-19 | 2022-09-09 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-08-19 | 2022-09-09 | 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 | 2022-08-19 | 2022-09-09 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-08-19 | 2022-09-09 | N |
| Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. | Health | 2022-08-19 | 2022-09-09 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-08-31 | 2022-09-01 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-08-31 | 2022-09-01 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-06-29 | 2022-07-15 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-09-01 | 2021-10-07 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-09-01 | 2021-10-07 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-09-08 | 2021-09-10 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-06-10 | 2021-06-11 | N |
| Assess the resident when there is a significant change in condition | Health | 2021-06-10 | 2021-06-11 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-06-10 | 2021-06-11 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-06-10 | 2021-06-11 | 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 | 2021-06-10 | 2021-06-11 | N |
| Post nurse staffing information every day. | Health | 2021-06-10 | 2021-06-11 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-06-10 | 2021-06-11 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-06-10 | 2021-06-11 | Y |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2021-06-10 | 2021-06-11 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-06-10 | 2021-06-11 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-06-09 | 2021-06-10 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-06-09 | 2021-06-10 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2021-06-09 | 2021-06-10 | N |
| Have an alternate power supply for its alarm system. | Fire Safety | 2021-06-09 | 2021-06-10 | N |
| Properly install and monitor supervisory attachments on automatic sprinkler systems. | Fire Safety | 2021-06-09 | 2021-06-10 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-06-09 | 2021-06-10 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-06-09 | 2021-06-10 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-06-09 | 2021-06-10 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-06-09 | 2021-06-10 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-03-24 | 2021-04-09 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-03-24 | 2021-04-09 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-03-24 | 2021-04-09 | Y |
