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Deficiency Records for Autumn Lake Healthcare at Ballenger Creek

A list of the most recent deficiencies for Autumn Lake Healthcare at Ballenger Creek. 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 Ballenger Creek. 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 each resident receives an accurate assessment. Health 2022-11-15 2023-02-16 Y
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2022-11-15 2023-02-16 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 2022-11-15 2023-01-16 N
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. Health 2022-11-15 2023-01-16 N
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Health 2022-11-15 2023-01-16 N
Ensure the activities program is directed by a qualified professional. Health 2022-11-15 2023-01-16 N
Observe each nurse aide's job performance and give regular training. Health 2022-11-15 2023-01-16 N
Post nurse staffing information every day. Health 2022-11-15 2023-01-16 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 2022-11-15 2023-01-16 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 2022-11-15 2023-01-16 N
Have a plan that describes the process for conducting QAPI and QAA activities. Health 2022-11-15 2023-01-16 N
Provide and implement an infection prevention and control program. Health 2022-11-15 2023-01-16 N
Let each resident or the resident's legal representative access or purchase copies of all the resident's records. Health 2022-11-15 2023-01-16 Y
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Health 2022-11-15 2023-01-16 Y
Develop and implement policies and procedures to prevent abuse, neglect, and theft. Health 2022-11-15 2023-01-16 Y
Respond appropriately to all alleged violations. Health 2022-11-15 2023-01-16 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 2022-11-15 2023-01-16 Y
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2022-11-15 2023-01-16 Y
Provide activities to meet all resident's needs. Health 2022-11-15 2023-01-16 Y
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2022-11-15 2023-01-16 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2022-11-15 2023-01-16 Y
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. Health 2022-11-15 2023-01-16 Y
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Health 2022-11-15 2023-01-16 Y
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 2022-11-15 2023-01-16 Y
Develop and maintain an Emergency Preparedness Program (EP). Fire Safety 2022-11-02 2022-12-15 N
Construct fire resistant interior walls. Fire Safety 2022-11-02 2022-12-15 N
Install an approved automatic sprinkler system. Fire Safety 2022-11-02 2022-12-15 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2022-11-02 2022-12-15 N
Install corridor and hallway doors that block smoke. Fire Safety 2022-11-02 2022-12-15 N
Have simulated fire drills held at unexpected times. Fire Safety 2022-11-02 2022-12-15 N
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2022-11-02 2022-12-15 N
Ensure that residents are free from significant medication errors. Health 2022-11-15 2022-11-15 Y
Develop and implement policies and procedures for flu and pneumonia vaccinations. Health 2022-02-09 2022-04-08 N
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. Health 2022-02-09 2022-04-08 N
Ensure each resident receives an accurate assessment. Health 2018-11-19 2019-01-02 N
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2018-11-19 2019-01-02 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 2018-11-19 2019-01-02 N
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2018-11-19 2019-01-02 N
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2018-11-19 2019-01-02 N
Ensure each resident?s drug regimen must be free from unnecessary drugs. Health 2018-11-19 2019-01-02 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 2018-11-19 2019-01-02 N
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Health 2018-11-19 2019-01-02 N
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Health 2018-11-19 2019-01-02 N
Provide and implement an infection prevention and control program. Health 2018-11-19 2019-01-02 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2018-11-19 2018-11-30 N
Reasonably accommodate the needs and preferences of each resident. Health 2018-04-18 2018-06-01 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 2018-04-18 2018-06-01 N
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. Health 2018-04-18 2018-06-01 N
Ensure each resident receives an accurate assessment. Health 2018-04-18 2018-06-01 N
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2018-04-18 2018-06-01 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 2018-04-18 2018-06-01 N
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Health 2018-04-18 2018-06-01 N
Assist a resident in gaining access to vision and hearing services. Health 2018-04-18 2018-06-01 N
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2018-04-18 2018-06-01 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 2018-04-18 2018-06-01 N
Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. Health 2018-04-18 2018-06-01 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 2018-04-18 2018-06-01 N
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 2018-04-18 2018-06-01 N
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Health 2018-04-18 2018-06-01 N
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Health 2018-04-18 2018-06-01 N
Have stairways and smokeproof enclosures used as exits that meet safety requirements. Fire Safety 2018-04-11 2018-05-21 N
Install smoke barrier doors that can resist smoke for at least 20 minutes. Fire Safety 2018-04-11 2018-05-21 N

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