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Deficiency Records for Autumn Lake Healthcare at Greenfield
A list of the most recent deficiencies for Autumn Lake Healthcare at Greenfield. 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 Greenfield. 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? |
|---|---|---|---|---|
| Ensure medication error rates are not 5 percent or greater. | Health | 2024-02-14 | 2024-03-06 | Y |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2024-02-14 | 2024-03-01 | Y |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2023-09-07 | 2024-02-29 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-11-21 | 2023-12-08 | Y |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-09-07 | 2023-10-26 | N |
| Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction. | Fire Safety | 2023-09-07 | 2023-10-13 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-09-07 | 2023-10-05 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-09-11 | 2023-09-30 | 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 | 2023-09-11 | 2023-09-30 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-09-11 | 2023-09-30 | 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 | 2023-09-11 | 2023-09-30 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-09-11 | 2023-09-30 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-09-11 | 2023-09-30 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-09-11 | 2023-09-30 | Y |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-09-07 | 2023-09-27 | 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 | 2023-09-07 | 2023-09-22 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-09-07 | 2023-09-22 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2023-09-07 | 2023-09-22 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-09-07 | 2023-09-22 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-09-07 | 2023-09-22 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-09-07 | 2023-09-22 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-09-07 | 2023-09-21 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-09-07 | 2023-09-21 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-06-13 | 2023-06-14 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-05-10 | 2023-06-14 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-05-10 | 2023-06-01 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-05-10 | 2023-05-31 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-05-10 | 2023-05-31 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-05-10 | 2023-05-31 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-05-10 | 2023-05-31 | Y |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2023-05-10 | 2023-05-31 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-05-10 | 2023-05-31 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-05-10 | 2023-05-30 | 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 | 2023-05-10 | 2023-05-30 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-05-10 | 2023-05-11 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-05-16 | 2022-09-26 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-05-16 | 2022-09-26 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-05-16 | 2022-09-24 | 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 | 2022-05-16 | 2022-09-24 | 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 | 2022-05-16 | 2022-09-24 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-05-16 | 2022-09-24 | 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 | 2022-05-16 | 2022-09-24 | 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 | 2022-05-16 | 2022-09-24 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-05-16 | 2022-09-24 | 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 | 2022-05-16 | 2022-09-24 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-05-16 | 2022-09-24 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2022-05-16 | 2022-09-24 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-05-16 | 2022-09-24 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-05-16 | 2022-09-24 | Y |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2022-05-16 | 2022-09-24 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-08-31 | 2022-09-01 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-08-31 | 2022-09-01 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-08-31 | 2022-09-01 | Y |
| Have exits that are accessible at all times. | Fire Safety | 2022-05-10 | 2022-07-30 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2022-05-10 | 2022-07-30 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-05-10 | 2022-07-30 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-05-10 | 2022-06-30 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-05-10 | 2022-06-30 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-05-10 | 2022-06-30 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-05-10 | 2022-06-25 | N |
| Establish emergency prep training and testing. | Fire Safety | 2022-05-10 | 2022-06-25 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2022-05-10 | 2022-06-09 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2022-05-10 | 2022-06-09 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-05-10 | 2022-06-06 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2022-05-10 | 2022-06-06 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-05-10 | 2022-06-04 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-05-10 | 2022-06-03 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-05-10 | 2022-06-02 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-05-10 | 2022-06-02 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-05-10 | 2022-06-01 | 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 | 2022-05-10 | 2022-06-01 | 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 | 2022-05-10 | 2022-06-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-05-10 | 2022-06-01 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-03-23 | 2022-03-25 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-02-02 | 2022-02-18 | Y |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-02-02 | 2022-02-18 | Y |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2021-03-08 | 2021-03-30 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-03-08 | 2021-03-30 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-03-08 | 2021-03-30 | 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 | 2021-03-08 | 2021-03-30 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-03-08 | 2021-03-30 | N |
| Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. | Health | 2021-03-08 | 2021-03-30 | 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 | 2021-03-08 | 2021-03-30 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-03-08 | 2021-03-30 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-03-08 | 2021-03-30 | N |
| Dispose of garbage and refuse properly. | Health | 2021-03-08 | 2021-03-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-03-08 | 2021-03-30 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-03-04 | 2021-03-22 | 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 | 2021-03-04 | 2021-03-22 | 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 | 2021-03-04 | 2021-03-22 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-03-04 | 2021-03-22 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2024-08-13 | Not Fixed | Y |
| 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 | 2024-08-13 | Not Fixed | Y |
| Respond appropriately to all alleged violations. | Health | 2024-08-13 | Not Fixed | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-08-13 | Not Fixed | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-08-13 | Not Fixed | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-08-13 | Not Fixed | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2024-08-13 | Not Fixed | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-08-13 | Not Fixed | Y |
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