Inspection visit
Inspection
Citations
37 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
- 0100GeneralS&S Dpotential for harm
Meet other general requirements.
- 0211GeneralS&S Dpotential for harm
Keep aisles, corridors, and exits free of obstruction in case of emergency.
- 0222GeneralS&S Dpotential for harm
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.
- 0232GeneralS&S Epotential for harm
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
- 0281GeneralS&S Dpotential for harm
Install proper backup exit lighting.
- 0321GeneralS&S Epotential for harm
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- 0324GeneralS&S Dpotential for harm
Provide properly protected cooking facilities.
- 0345GeneralS&S Dpotential for harm
Have approved installation, maintenance and testing program for fire alarm systems.
- 0353GeneralS&S Dpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0362GeneralS&S Dpotential for harm
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
- 0511GeneralS&S Dpotential for harm
Have properly installed electrical wiring and gas equipment.
F741 - The facility must have sufficient staff who provide direct services to
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
F761 - Labeling of Drugs and Biologicals
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.
- 0781GeneralS&S Dpotential for harm
Have restrictions on the use of portable space heaters.
F918 - Bathroom Facilities
Have generator or other power source capable of supplying service within 10 seconds.
F923 - Have adequate outside ventilation by means of windows, or mechanical
Have proper medical gas storage and administration areas.
F550 - Resident Rights
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
F558 - The right to reside and receive services in the facility with reasonable
Reasonably accommodate the needs and preferences of each resident.
F559 - The right to share a room with his or her spouse when married residents live
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
F584 - Safe Environment
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.
F600 - Freedom from Abuse, Neglect, and Exploitation
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
F603 - The resident has the right to be free from abuse, neglect, misappropriation
Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).
F610 - In response to allegations of abuse, neglect, exploitation, or mistreatment, the
Respond appropriately to all alleged violations.
F636 - Resident Assessment
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
F638 - Quarterly Review Assessment
Assure that each resident’s assessment is updated at least once every 3 months.
F641 - Accuracy of Assessments
Ensure each resident receives an accurate assessment.
F657 - Comprehensive Care Plans
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
F677 - A resident who is unable to carry out activities of daily living receives
Provide care and assistance to perform activities of daily living for any resident who is unable.
F679 - Activities
Provide activities to meet all resident's needs.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F692 - Assisted nutrition and hydration
Provide enough food/fluids to maintain a resident's health.
F732 - Nurse Staffing Information
Post nurse staffing information every day.
F740 - Behavioral health services
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F835 - Administration
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
F842 - Resident-identifiable information
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
F921 - Other Environmental Conditions
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
FAQ · About this visit
Common questions about this visit
What happened during the February 3, 2023 survey of AUTUMN LAKE HEALTHCARE AT SPA CREEK?
This was a inspection survey of AUTUMN LAKE HEALTHCARE AT SPA CREEK on February 3, 2023. The surveyor cited 37 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at AUTUMN LAKE HEALTHCARE AT SPA CREEK on February 3, 2023?
Yes, 37 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Meet other general requirements."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.