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Deficiency Records for Autumn Lake Healthcare at Berkeley Heights
A list of the most recent deficiencies for Autumn Lake Healthcare at Berkeley Heights. 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 Berkeley Heights. 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? |
|---|---|---|---|---|
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-07-19 | 2024-09-10 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-07-19 | 2024-09-10 | 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 | 2024-07-19 | 2024-09-10 | 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 | 2024-07-19 | 2024-09-10 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-07-19 | 2024-09-10 | N |
| Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training. | Health | 2024-07-19 | 2024-09-10 | N |
| Post nurse staffing information every day. | Health | 2024-07-19 | 2024-09-10 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-07-19 | 2024-09-10 | 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 | 2024-07-19 | 2024-09-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-07-19 | 2024-09-10 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2024-07-19 | 2024-09-10 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2024-07-19 | 2024-09-10 | N |
| Respond appropriately to all alleged violations. | Health | 2024-07-19 | 2024-09-10 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-07-19 | 2024-09-10 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-07-19 | 2024-09-10 | Y |
| 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 | 2024-07-19 | 2024-09-10 | 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 | 2024-07-19 | 2024-09-10 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-07-19 | 2024-09-10 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-07-19 | 2024-09-10 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-07-19 | 2024-09-10 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2024-07-19 | 2024-09-10 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2024-07-19 | 2024-09-10 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2024-07-19 | 2024-09-10 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-07-19 | 2024-09-10 | N |
| Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | Fire Safety | 2024-07-19 | 2024-09-10 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2022-11-15 | 2023-01-24 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-11-15 | 2023-01-19 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-11-15 | 2022-12-16 | N |
| Install proper backup exit lighting. | Fire Safety | 2022-11-15 | 2022-12-16 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-11-15 | 2022-12-16 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-11-15 | 2022-12-16 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2022-11-15 | 2022-12-16 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-11-15 | 2022-12-16 | N |
| Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | Fire Safety | 2022-11-15 | 2022-12-16 | 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 | 2022-11-15 | 2022-11-24 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-11-15 | 2022-11-24 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2022-11-15 | 2022-11-24 | N |
| Report COVID19 data to residents and families. | Health | 2022-02-01 | 2022-02-18 | N |
| Perform COVID19 testing on residents and staff. | Health | 2022-02-01 | 2022-02-18 | 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 | 2022-02-01 | 2022-02-18 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2020-09-23 | 2020-10-14 | 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 | 2020-09-23 | 2020-10-13 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-09-23 | 2020-10-13 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-09-23 | 2020-10-13 | N |
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