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Deficiency Records for Autumn Lake Healthcare at Chevy Chase
A list of the most recent deficiencies for Autumn Lake Healthcare at Chevy Chase. 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 Chevy Chase. 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? |
|---|---|---|---|---|
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-02-24 | 2022-04-05 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-03-26 | 2021-05-06 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-03-26 | 2021-05-06 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-03-26 | 2021-05-06 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-03-26 | 2021-05-06 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-03-26 | 2021-05-06 | 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 | 2021-03-26 | 2021-05-06 | 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 | 2021-03-26 | 2021-05-06 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-03-26 | 2021-05-06 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-03-25 | 2021-04-29 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-03-25 | 2021-04-29 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-03-25 | 2021-04-29 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-03-25 | 2021-04-29 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2021-03-25 | 2021-04-29 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-03-25 | 2021-04-29 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-03-25 | 2021-04-29 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-03-25 | 2021-04-29 | 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 | 2019-06-21 | 2019-08-01 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-06-21 | 2019-08-01 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-06-21 | 2019-08-01 | 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 | 2019-06-21 | 2019-08-01 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-06-21 | 2019-08-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-06-21 | 2019-08-01 | N |
| Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service. | Health | 2019-06-21 | 2019-08-01 | 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 | 2019-06-18 | 2019-06-28 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-06-18 | 2019-06-28 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2019-06-18 | 2019-06-28 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2019-06-18 | 2019-06-28 | 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 | 2018-06-12 | 2018-08-10 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-06-12 | 2018-08-10 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-06-12 | 2018-07-26 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2018-06-08 | 2018-07-19 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2018-06-08 | 2018-07-19 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2018-06-08 | 2018-07-19 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-06-08 | 2018-07-19 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-06-08 | 2018-07-19 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-06-08 | 2018-07-19 | 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 | 2018-06-08 | 2018-07-19 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2018-06-08 | 2018-07-19 | N |
| Provide activities to meet all resident's needs. | Health | 2018-06-08 | 2018-07-19 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-06-08 | 2018-07-19 | 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 | 2018-06-08 | 2018-07-19 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2018-06-08 | 2018-07-19 | 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 | 2018-06-08 | 2018-07-19 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-06-08 | 2018-07-19 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2018-06-08 | 2018-07-19 | N |
| Implement a program that monitors antibiotic use. | Health | 2018-06-08 | 2018-07-19 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-06-12 | 2018-07-19 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2018-06-12 | 2018-07-19 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2018-06-12 | 2018-07-19 | N |
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