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Deficiency Records for Autumn Lake Healthcare at Madison
A list of the most recent deficiencies for Autumn Lake Healthcare at Madison. 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 Lake Healthcare at Madison. 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? |
|---|---|---|---|---|
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-03-06 | 2024-04-15 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-03-06 | 2024-04-15 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-11-13 | 2024-01-25 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2023-11-13 | 2024-01-25 | 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 | 2023-11-13 | 2024-01-25 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-11-13 | 2024-01-25 | 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 | 2023-11-13 | 2024-01-25 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2023-11-13 | 2024-01-25 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-11-13 | 2024-01-25 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-11-13 | 2024-01-25 | 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 | 2023-11-13 | 2024-01-25 | 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 | 2023-11-13 | 2024-01-25 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-11-13 | 2024-01-25 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-11-13 | 2024-01-25 | N |
| Provide appropriate foot care. | Health | 2023-11-13 | 2024-01-25 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-11-13 | 2024-01-25 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-11-13 | 2024-01-25 | 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 | 2023-11-13 | 2024-01-25 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2023-11-13 | 2024-01-25 | N |
| 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 | 2023-11-13 | 2024-01-25 | N |
| Provide or obtain dental services for each resident. | Health | 2023-11-13 | 2024-01-25 | N |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2023-11-13 | 2024-01-25 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-11-13 | 2024-01-25 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-11-13 | 2024-01-25 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2023-11-13 | 2024-01-25 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-11-07 | 2024-01-09 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-11-07 | 2024-01-09 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2023-11-07 | 2023-12-18 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2023-11-07 | 2023-12-18 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2023-11-07 | 2023-12-18 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2023-11-07 | 2023-12-18 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-11-07 | 2023-12-18 | 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 | 2023-11-07 | 2023-12-18 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-11-07 | 2023-12-18 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-11-07 | 2023-12-18 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-11-07 | 2023-12-18 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-11-07 | 2023-12-18 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-11-07 | 2023-12-18 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-11-07 | 2023-12-18 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-11-07 | 2023-12-18 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-11-07 | 2023-12-18 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2023-11-07 | 2023-12-18 | 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 | 2023-09-27 | 2023-11-30 | Y |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2023-09-27 | 2023-11-30 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-06-14 | 2023-07-21 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-02-27 | 2023-04-14 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-01-17 | 2023-03-10 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-11-03 | 2022-11-22 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-09-23 | 2022-10-12 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-01-10 | 2022-10-03 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-01-10 | 2022-10-03 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-06-30 | 2022-08-04 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-06-30 | 2022-08-04 | Y |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2022-06-30 | 2022-08-04 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-06-13 | 2022-07-08 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-06-13 | 2022-07-08 | Y |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2022-06-13 | 2022-07-08 | 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 | 2022-04-19 | 2022-06-01 | 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 | 2022-04-19 | 2022-06-01 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-04-19 | 2022-06-01 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-04-19 | 2022-06-01 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-04-19 | 2022-06-01 | 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 | 2021-07-14 | 2021-08-03 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-07-14 | 2021-08-03 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-07-14 | 2021-08-03 | N |
| 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 | 2021-07-14 | 2021-08-03 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-07-14 | 2021-08-03 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-07-14 | 2021-08-03 | 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 | 2021-07-14 | 2021-08-03 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-07-14 | 2021-08-03 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-03-27 | 2019-06-03 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-03-27 | 2019-06-03 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-03-27 | 2019-06-03 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-03-27 | 2019-06-03 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2019-03-28 | 2019-05-02 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-03-28 | 2019-05-02 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2019-03-28 | 2019-05-02 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-03-28 | 2019-05-02 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-03-28 | 2019-05-02 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-03-28 | 2019-05-02 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2019-03-28 | 2019-05-02 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2019-03-28 | 2019-05-02 | N |
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