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Deficiency Records for Advanced Rehab at Autumn Lake Healthcare
A list of the most recent deficiencies for Advanced Rehab at Autumn Lake Healthcare. 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 Advanced Rehab at Autumn Lake Healthcare. 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? |
|---|---|---|---|---|
| Establish an Emergency Preparedness Program (EP). | Fire Safety | 2024-06-26 | 2024-10-03 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2024-06-26 | 2024-10-03 | 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 | 2024-06-26 | 2024-10-03 | 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 | 2024-06-26 | 2024-10-03 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-06-26 | 2024-10-03 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2024-06-26 | 2024-10-03 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-06-26 | 2024-10-03 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2024-06-26 | 2024-10-03 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-06-26 | 2024-10-03 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2024-06-26 | 2024-10-03 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-06-26 | 2024-10-03 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2024-06-26 | 2024-10-03 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-06-26 | 2024-10-03 | N |
| Provide properly sized and located linen or trash receptacles. | Fire Safety | 2024-06-26 | 2024-10-03 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2024-06-26 | 2024-10-03 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2024-06-26 | 2024-10-03 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-06-26 | 2024-10-03 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-06-28 | 2024-08-14 | 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 | 2024-06-28 | 2024-08-14 | 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 | 2024-06-28 | 2024-08-14 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2024-06-28 | 2024-08-14 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-06-28 | 2024-08-14 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-06-28 | 2024-08-14 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-06-28 | 2024-08-14 | 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 | 2024-06-28 | 2024-08-14 | N |
| Provide or obtain dental services for each resident. | Health | 2024-06-28 | 2024-08-14 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-06-28 | 2024-08-14 | Y |
| Respond appropriately to all alleged violations. | Health | 2024-06-28 | 2024-08-14 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-06-28 | 2024-08-14 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-06-28 | 2024-08-14 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-06-28 | 2024-08-14 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-01-11 | 2024-02-07 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-01-11 | 2024-01-08 | Y |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2021-11-18 | 2022-01-14 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-11-18 | 2022-01-14 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-11-18 | 2022-01-14 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-11-18 | 2022-01-14 | 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 | 2021-11-18 | 2022-01-14 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-11-18 | 2022-01-14 | Y |
| Observe each nurse aide's job performance and give regular training. | Health | 2019-09-03 | 2019-09-30 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-09-03 | 2019-09-30 | 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 | 2019-09-03 | 2019-09-30 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2019-09-03 | 2019-09-30 | 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 | 2019-09-09 | 2019-09-30 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-09-09 | 2019-09-30 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-09-09 | 2019-09-30 | N |
| Meet other general requirements. | Fire Safety | 2018-06-25 | 2018-08-03 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-06-25 | 2018-08-03 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-06-25 | 2018-08-03 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-06-25 | 2018-07-02 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2018-06-25 | 2018-07-02 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-06-25 | 2018-06-30 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-05-15 | 2018-06-27 | N |
| Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. | Health | 2018-05-15 | 2018-06-27 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2018-05-15 | 2018-06-27 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-05-15 | 2018-06-27 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-05-15 | 2018-06-27 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2018-05-15 | 2018-06-27 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-05-15 | 2018-06-27 | 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 | 2018-05-15 | 2018-06-27 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2018-05-15 | 2018-06-27 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-05-15 | 2018-06-27 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-05-15 | 2018-06-27 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2018-05-15 | 2018-06-27 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2018-05-15 | 2018-06-27 | 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 | 2018-05-15 | 2018-06-27 | 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 | 2018-05-15 | 2018-06-27 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2018-05-15 | 2018-06-27 | N |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2018-05-15 | 2018-06-27 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-05-15 | 2018-06-27 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-05-15 | 2018-06-27 | N |
| Keep all essential equipment working safely. | Health | 2018-05-15 | 2018-06-27 | N |
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