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Deficiency Records for Autumn Woods Residential Hlth
A list of the most recent deficiencies for Autumn Woods Residential Hlth. 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 Woods Residential Hlth. 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? |
|---|---|---|---|---|
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-07-25 | 2024-08-19 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-07-25 | 2024-08-19 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-07-25 | 2024-08-19 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-07-25 | 2024-08-19 | Y |
| 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 | 2024-07-25 | 2024-08-19 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2024-07-25 | 2024-08-19 | Y |
| Provide properly protected cooking facilities. | Fire Safety | 2024-07-24 | 2024-08-19 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-07-24 | 2024-08-19 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-07-24 | 2024-08-19 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-03-12 | 2024-04-01 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-03-12 | 2024-04-01 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-10-30 | 2023-11-17 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-10-30 | 2023-11-17 | Y |
| 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 | 2023-08-21 | 2023-09-11 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-08-21 | 2023-09-11 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-05-24 | 2023-06-16 | 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 | 2023-05-24 | 2023-06-16 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-05-24 | 2023-06-16 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-05-24 | 2023-06-16 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-05-24 | 2023-06-16 | Y |
| 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 | 2023-05-24 | 2023-06-16 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-05-24 | 2023-06-16 | Y |
| Address subsistence needs for staff and patients. | Fire Safety | 2023-05-22 | 2023-06-16 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-05-22 | 2023-06-16 | 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 | 2023-05-22 | 2023-06-16 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-05-22 | 2023-06-16 | 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 | 2023-05-22 | 2023-06-16 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2023-05-22 | 2023-06-16 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-05-22 | 2023-06-16 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-05-22 | 2023-06-16 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-05-22 | 2023-06-16 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-05-22 | 2023-06-16 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2023-05-22 | 2023-06-16 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-05-22 | 2023-06-16 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-02-01 | 2023-02-17 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-08-18 | 2022-09-14 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2022-08-18 | 2022-09-14 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-08-18 | 2022-09-14 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-08-18 | 2022-09-14 | Y |
| 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 | 2022-08-18 | 2022-09-14 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-05-04 | 2022-06-24 | 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 | 2022-05-04 | 2022-06-01 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-05-04 | 2022-06-01 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-05-04 | 2022-06-01 | Y |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2022-05-04 | 2022-06-01 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2022-05-04 | 2022-06-01 | 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 | 2022-05-04 | 2022-06-01 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-05-04 | 2022-06-01 | 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 | 2022-05-04 | 2022-06-01 | 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 | 2022-05-04 | 2022-06-01 | 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 | 2022-05-04 | 2022-06-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-05-04 | 2022-06-01 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-05-04 | 2022-06-01 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-05-04 | 2022-06-01 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-05-04 | 2022-06-01 | 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 | 2022-05-04 | 2022-06-01 | Y |
| Meet other general requirements. | Fire Safety | 2022-04-28 | 2022-06-01 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-04-28 | 2022-06-01 | 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 | 2022-04-28 | 2022-06-01 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2022-04-28 | 2022-06-01 | N |
| Have exits that are accessible at all times. | Fire Safety | 2022-04-28 | 2022-06-01 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-04-28 | 2022-06-01 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-04-28 | 2022-06-01 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-04-28 | 2022-06-01 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2022-04-28 | 2022-06-01 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-04-28 | 2022-06-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-04-28 | 2022-06-01 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-04-28 | 2022-06-01 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-04-28 | 2022-06-01 | N |
| Have properly sized and located compartments to protect residents from smoke. | Fire Safety | 2022-04-28 | 2022-06-01 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-04-28 | 2022-06-01 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-04-28 | 2022-06-01 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2022-04-28 | 2022-06-01 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2022-04-28 | 2022-06-01 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-04-28 | 2022-06-01 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-04-28 | 2022-06-01 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-04-28 | 2022-06-01 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-04-28 | 2022-06-01 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-04-28 | 2022-06-01 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-03-22 | 2022-04-15 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-03-22 | 2022-04-15 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-03-10 | 2022-04-08 | 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 | 2022-03-10 | 2022-04-08 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-12-20 | 2022-01-14 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-12-20 | 2022-01-14 | Y |
| Provide appropriate foot care. | Health | 2021-12-20 | 2022-01-14 | Y |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2021-12-20 | 2022-01-14 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2021-12-08 | 2021-12-16 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-10-27 | 2021-11-09 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-10-27 | 2021-11-09 | 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 | 2021-10-27 | 2021-11-09 | Y |
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