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Deficiency Records for Autumn Lake Healthcare at Oakview

A list of the most recent deficiencies for Autumn Lake Healthcare at Oakview. 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 Oakview. 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 request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. Health 2023-11-03 2024-01-04 N
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Health 2023-11-03 2024-01-04 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 2023-11-03 2024-01-04 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 2023-11-03 2024-01-04 N
Assess the resident when there is a significant change in condition Health 2023-11-03 2024-01-04 N
Ensure each resident receives an accurate assessment. Health 2023-11-03 2024-01-04 N
PASARR screening for Mental disorders or Intellectual Disabilities Health 2023-11-03 2024-01-04 N
Provide activities to meet all resident's needs. Health 2023-11-03 2024-01-04 N
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Health 2023-11-03 2024-01-04 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 2023-11-03 2024-01-04 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 2023-11-03 2024-01-04 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 2023-11-03 2024-01-04 N
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Health 2023-11-03 2024-01-04 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2023-11-03 2024-01-04 N
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Health 2023-11-03 2024-01-04 N
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Health 2023-11-03 2024-01-04 N
Provide and implement an infection prevention and control program. Health 2023-11-03 2024-01-04 N
Make sure that a working call system is available in each resident's bathroom and bathing area. Health 2023-11-03 2024-01-04 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 2023-11-03 2024-01-04 N
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2023-11-03 2024-01-04 Y
Respond appropriately to all alleged violations. Health 2023-11-03 2024-01-04 Y
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Health 2023-11-03 2024-01-04 Y
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Health 2023-11-03 2024-01-04 Y
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2023-11-03 2024-01-04 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 2023-11-03 2024-01-04 Y
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Health 2023-11-03 2024-01-04 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2023-11-03 2024-01-04 Y
Provide enough food/fluids to maintain a resident's health. Health 2023-11-03 2024-01-04 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 2023-11-03 2024-01-04 Y
Ensure each resident?s drug regimen must be free from unnecessary drugs. Health 2023-11-03 2024-01-04 Y
Develop and maintain an Emergency Preparedness Program (EP). Fire Safety 2023-11-08 2023-12-08 N
Meet other general requirements. Fire Safety 2023-11-08 2023-12-08 N
Keep aisles, corridors, and exits free of obstruction in case of emergency. Fire Safety 2023-11-08 2023-12-08 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 2023-11-08 2023-12-08 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2023-11-08 2023-12-08 N
Properly select, install, inspect, or maintain portable fire extinguishes. Fire Safety 2023-11-08 2023-12-08 N
Install corridor and hallway doors that block smoke. Fire Safety 2023-11-08 2023-12-08 N
Have simulated fire drills held at unexpected times. Fire Safety 2023-11-08 2023-12-08 N
To conduct inspection, testing and maintenance of fire doors by qualified individuals. Fire Safety 2023-11-08 2023-12-08 N
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. Fire Safety 2023-11-08 2023-12-08 N
Have proper medical gas storage and administration areas. Fire Safety 2023-11-08 2023-12-08 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 2019-10-25 2019-12-25 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 2019-10-25 2019-12-25 N
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Health 2019-10-25 2019-12-25 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 2019-10-25 2019-12-25 N
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2019-10-25 2019-12-25 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 2019-10-25 2019-12-25 N
Ensure services provided by the nursing facility meet professional standards of quality. Health 2019-10-25 2019-12-25 N
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2019-10-25 2019-12-25 N
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2019-10-25 2019-12-25 N
Provide safe, appropriate dialysis care/services for a resident who requires such services. Health 2019-10-25 2019-12-25 N
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. Health 2019-10-25 2019-12-25 N
Ensure each resident must receive and the facility must provide necessary behavioral health care and services. Health 2019-10-25 2019-12-25 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 2019-10-25 2019-12-25 N
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. Health 2019-10-25 2019-12-25 N
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Health 2019-10-25 2019-12-25 N
Provide and implement an infection prevention and control program. Health 2019-10-25 2019-12-25 N
Have policies on smoking. Health 2019-10-25 2019-12-25 N
Meet other general requirements. Fire Safety 2019-10-23 2019-12-18 N
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. Fire Safety 2019-10-23 2019-12-18 N
Install an approved automatic sprinkler system. Fire Safety 2019-10-23 2019-12-18 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2019-10-23 2019-12-18 N
Have properly located and lighted "Exit" signs. Fire Safety 2019-02-05 2019-04-03 N
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. Fire Safety 2019-02-05 2019-04-03 N
Install an approved automatic sprinkler system. Fire Safety 2019-02-05 2019-04-03 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2019-02-05 2019-04-03 N
Install corridor and hallway doors that block smoke. Fire Safety 2019-02-05 2019-04-03 N
Install smoke barrier doors that can resist smoke for at least 20 minutes. Fire Safety 2019-02-05 2019-04-03 N
Meet requirements for the installation and maintenance of electrical systems. Fire Safety 2019-02-05 2019-04-03 N
Ensure that testing and maintenance of electrical equipment is performed. Fire Safety 2019-02-05 2019-04-03 N
Have proper medical gas storage and administration areas. Fire Safety 2019-02-05 2019-04-03 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 2018-11-13 2018-12-14 N
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Health 2018-11-13 2018-12-14 N
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. Health 2018-11-13 2018-12-14 N
Assure that each resident?s assessment is updated at least once every 3 months. Health 2018-11-13 2018-12-14 N
Ensure each resident receives an accurate assessment. Health 2018-11-13 2018-12-14 N
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2018-11-13 2018-12-14 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 2018-11-13 2018-12-14 N
Ensure services provided by the nursing facility meet professional standards of quality. Health 2018-11-13 2018-12-14 N
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2018-11-13 2018-12-14 N
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2018-11-13 2018-12-14 N
Ensure each resident must receive and the facility must provide necessary behavioral health care and services. Health 2018-11-13 2018-12-14 N
Provide and implement an infection prevention and control program. Health 2018-11-13 2018-12-14 N

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