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Deficiency Records for Autumn Creek Post Acute
A list of the most recent deficiencies for Autumn Creek Post Acute. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Autumn Creek Post Acute. 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? |
|---|---|---|---|---|
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-08-26 | 2024-09-10 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2024-08-26 | 2024-09-10 | Y |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2024-06-11 | 2024-06-25 | Y |
| Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. | Health | 2024-06-11 | 2024-06-25 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-06-15 | 2024-06-18 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-05-24 | 2024-06-12 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-05-24 | 2024-06-12 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2024-05-24 | 2024-06-12 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2024-05-24 | 2024-06-12 | Y |
| 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 | 2024-05-24 | 2024-06-12 | Y |
| Keep all essential equipment working safely. | Health | 2024-05-24 | 2024-06-12 | Y |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2024-03-12 | 2024-03-25 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-03-13 | 2024-03-21 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2024-03-13 | 2024-03-21 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-02-26 | 2024-03-08 | Y |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2024-01-19 | 2024-02-23 | N |
| Ensure each resident receives an accurate assessment. | Health | 2024-01-19 | 2024-02-23 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-01-19 | 2024-02-23 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-01-19 | 2024-02-23 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2024-01-19 | 2024-02-23 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2024-01-19 | 2024-02-23 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2024-01-24 | 2024-02-21 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2024-01-24 | 2024-02-21 | N |
| Develop a communication plan. | Fire Safety | 2024-01-24 | 2024-02-21 | N |
| Establish emergency prep training and testing. | Fire Safety | 2024-01-24 | 2024-02-21 | N |
| Implement emergency and standby power systems. | Fire Safety | 2024-01-24 | 2024-02-21 | 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 | 2024-01-24 | 2024-02-21 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-01-24 | 2024-02-21 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2024-01-24 | 2024-02-21 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-01-24 | 2024-02-21 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2024-01-24 | 2024-02-21 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-01-24 | 2024-02-21 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-01-24 | 2024-02-21 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-01-11 | 2024-01-29 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-01-11 | 2024-01-29 | Y |
| Honor each resident's preferences, choices, values and beliefs. | Health | 2024-01-10 | 2024-01-26 | Y |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2024-01-09 | 2024-01-19 | 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 | 2024-01-09 | 2024-01-19 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-01-09 | 2024-01-19 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-12-11 | 2023-12-26 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-12-20 | 2023-12-22 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-12-05 | 2023-12-22 | Y |
| 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 | 2023-12-05 | 2023-12-22 | Y |
| 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 | 2023-09-22 | 2023-10-19 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-09-22 | 2023-10-19 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-09-22 | 2023-10-19 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-09-22 | 2023-10-19 | Y |
| Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. | Health | 2023-09-22 | 2023-10-19 | Y |
| Keep all essential equipment working safely. | Health | 2023-09-22 | 2023-10-19 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-09-13 | 2023-10-09 | Y |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2023-09-13 | 2023-10-09 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-09-13 | 2023-10-09 | Y |
| 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 | 2023-08-09 | 2023-08-22 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-05-16 | 2023-06-12 | Y |
| 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 | 2023-05-16 | 2023-06-12 | Y |
| Provide or obtain dental services for each resident. | Health | 2023-05-16 | 2023-06-12 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-05-16 | 2023-06-12 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-05-09 | 2023-05-18 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-03-21 | 2023-04-20 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-03-21 | 2023-04-20 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-03-21 | 2023-04-20 | Y |
| 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 | 2023-03-21 | 2023-04-20 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-03-15 | 2023-03-28 | Y |
| 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 | 2023-02-28 | 2023-03-21 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-02-28 | 2023-03-21 | Y |
| 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 | 2023-02-15 | 2023-03-10 | Y |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2023-02-15 | 2023-03-10 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-01-20 | 2023-02-16 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-01-20 | 2023-02-16 | Y |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2022-12-28 | 2023-01-17 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-11-10 | 2022-11-22 | Y |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2022-11-10 | 2022-11-22 | 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 | 2022-11-02 | 2022-11-11 | Y |
| 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 | 2022-11-02 | 2022-11-11 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-11-02 | 2022-11-11 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-10-11 | 2022-10-25 | Y |
| Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Health | 2022-09-28 | 2022-10-11 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-09-28 | 2022-10-11 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-09-28 | 2022-10-11 | 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 | 2022-09-28 | 2022-10-11 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-05-03 | 2022-05-24 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-02-09 | 2022-03-11 | N |
| Perform COVID19 testing on residents and staff. | Health | 2022-02-09 | 2022-03-11 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-02-04 | 2022-02-24 | Y |
| 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 | 2021-08-12 | 2021-09-14 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-08-12 | 2021-09-14 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-08-12 | 2021-09-14 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2021-08-12 | 2021-09-14 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-08-12 | 2021-09-14 | 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 | 2021-08-12 | 2021-09-14 | N |
| Keep all essential equipment working safely. | Health | 2021-08-12 | 2021-09-14 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2021-08-17 | 2021-09-13 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2021-08-17 | 2021-09-13 | N |
| Use approved construction type or materials. | Fire Safety | 2021-08-17 | 2021-09-13 | N |
| Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. | Fire Safety | 2021-08-17 | 2021-09-13 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-08-17 | 2021-09-13 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-08-17 | 2021-09-13 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-08-17 | 2021-09-13 | N |
| Develop and implement policies and procedures to ensure (1) employees report any suspicion of a crime against any resident, according to timelines; (2) post the notice of employee rights; and (3) prohibit and prevent retaliation for reporting. | Health | 2019-08-30 | 2019-10-16 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-08-30 | 2019-10-16 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-08-30 | 2019-10-16 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-08-30 | 2019-10-16 | 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 | 2019-08-30 | 2019-10-16 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-08-30 | 2019-10-16 | 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 | 2019-08-30 | 2019-10-16 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-08-30 | 2019-10-16 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2019-08-30 | 2019-10-16 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2019-08-30 | 2019-10-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-08-30 | 2019-10-16 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-08-30 | 2019-10-16 | N |
| Use approved construction type or materials. | Fire Safety | 2019-09-13 | 2019-09-23 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-09-13 | 2019-09-23 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-09-13 | 2019-09-23 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-09-13 | 2019-09-23 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-09-13 | 2019-09-23 | N |
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