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Deficiency Records for Autumn Care of Suffolk
A list of the most recent deficiencies for Autumn Care of Suffolk. 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 Care of Suffolk. 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 properly protected cooking facilities. | Fire Safety | 2021-06-24 | 2021-12-02 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-06-24 | 2021-12-02 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-06-24 | 2021-12-02 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-06-24 | 2021-12-02 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-06-24 | 2021-12-02 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-06-24 | 2021-12-02 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-06-24 | 2021-12-02 | 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 | 2021-06-24 | 2021-08-12 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-06-24 | 2021-08-12 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2021-06-24 | 2021-08-12 | N |
| Have restrictions on the use of flammable curtains. | Fire Safety | 2021-06-24 | 2021-08-12 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2021-06-24 | 2021-08-12 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-06-24 | 2021-08-12 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-06-21 | 2021-07-23 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2021-06-21 | 2021-07-23 | 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 | 2021-06-21 | 2021-07-23 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-06-21 | 2021-07-23 | 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 | 2021-06-21 | 2021-07-23 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-06-21 | 2021-07-23 | N |
| Respond appropriately to all alleged violations. | Health | 2021-06-21 | 2021-07-23 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2021-06-21 | 2021-07-23 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-06-21 | 2021-07-23 | 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 | 2021-06-21 | 2021-07-23 | 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 | 2021-06-21 | 2021-07-23 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-06-21 | 2021-07-23 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-06-21 | 2021-07-23 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-06-21 | 2021-07-23 | N |
| Provide appropriate foot care. | Health | 2021-06-21 | 2021-07-23 | 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 | 2021-06-21 | 2021-07-23 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2021-06-21 | 2021-07-23 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. | Health | 2021-06-21 | 2021-07-23 | 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 | 2021-06-21 | 2021-07-23 | N |
| Ensure that residents are free from significant medication errors. | Health | 2021-06-21 | 2021-07-23 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-06-21 | 2021-07-23 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-06-21 | 2021-07-23 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2021-06-21 | 2021-07-23 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2021-06-21 | 2021-07-23 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2021-06-21 | 2021-07-23 | N |
| Establish emergency prep training and testing. | Fire Safety | 2021-06-21 | 2021-07-23 | N |
| Establish staff and initial training requirements. | Fire Safety | 2021-06-21 | 2021-07-23 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2021-06-21 | 2021-07-23 | 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 | 2019-07-26 | 2019-09-18 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-07-26 | 2019-09-18 | 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 | 2019-08-06 | 2019-09-11 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2019-08-06 | 2019-09-11 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-08-06 | 2019-09-11 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-08-06 | 2019-09-11 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-08-06 | 2019-09-11 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-07-26 | 2019-08-26 | 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 | 2019-07-26 | 2019-08-26 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2019-07-26 | 2019-08-26 | 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 | 2019-07-26 | 2019-08-26 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-07-26 | 2019-08-26 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-07-26 | 2019-08-26 | N |
| Provide appropriate foot care. | Health | 2019-07-26 | 2019-08-26 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-07-26 | 2019-08-26 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-07-26 | 2019-08-26 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-07-26 | 2019-08-26 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-07-26 | 2019-08-26 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-07-26 | 2019-08-26 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2019-07-26 | 2019-08-26 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2019-07-26 | 2019-08-26 | N |
| Establish emergency prep training and testing. | Fire Safety | 2019-07-26 | 2019-08-26 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2018-02-27 | 2018-04-20 | 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 | 2018-02-27 | 2018-04-20 | N |
| Have exits that are accessible at all times. | Fire Safety | 2018-02-27 | 2018-04-20 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2018-02-27 | 2018-04-20 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2018-02-27 | 2018-04-20 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-02-27 | 2018-04-20 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2018-02-27 | 2018-04-20 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2018-02-27 | 2018-04-20 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2018-01-26 | 2018-04-04 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-01-26 | 2018-04-04 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-01-26 | 2018-03-08 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-01-26 | 2018-03-08 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-01-26 | 2018-03-08 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-01-26 | 2018-03-08 | 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 | 2018-01-26 | 2018-03-08 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2018-01-26 | 2018-03-07 | N |
| Honor the resident's right to manage his or her financial affairs. | Health | 2018-01-26 | 2018-03-07 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2018-01-26 | 2018-03-07 | N |
| Respond appropriately to all alleged violations. | Health | 2018-01-26 | 2018-03-07 | N |
| Ensure a qualified health professional conducts resident assessments. | Health | 2018-01-26 | 2018-03-07 | 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 | 2018-01-26 | 2018-03-07 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2018-01-26 | 2018-03-07 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-01-26 | 2018-03-07 | N |
| Establish emergency prep training and testing. | Fire Safety | 2018-01-26 | 2018-03-07 | N |
| Establish staff and initial training requirements. | Fire Safety | 2018-01-26 | 2018-03-07 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2018-01-26 | 2017-12-05 | N |
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