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Deficiency Records for Autumn Lake Healthcare at Pikesville

A list of the most recent deficiencies for Autumn Lake Healthcare at Pikesville. 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 Pikesville. 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?
Give residents a notice of rights, rules, services and charges. Health 2023-02-17 2023-04-14 Y
Let each resident or the resident's legal representative access or purchase copies of all the resident's records. Health 2023-02-17 2023-04-14 Y
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Health 2023-02-17 2023-04-14 Y
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. Health 2023-02-17 2023-04-14 Y
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Health 2023-02-17 2023-04-14 Y
Ensure each resident?s drug regimen must be free from unnecessary drugs. Health 2023-02-17 2023-04-14 Y
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 2022-08-11 2022-11-24 N
Prepare residents for a safe transfer or discharge from the nursing home. Health 2022-08-11 2022-11-24 N
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2022-08-11 2022-11-24 N
Post nurse staffing information every day. Health 2022-08-11 2022-11-24 N
Ensure each resident?s drug regimen must be free from unnecessary drugs. Health 2022-08-11 2022-11-24 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 2022-08-11 2022-11-24 N
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Health 2022-08-11 2022-11-24 N
Keep all essential equipment working safely. Health 2022-08-11 2022-11-24 N
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Health 2022-08-11 2022-10-03 N
Reasonably accommodate the needs and preferences of each resident. Health 2022-08-11 2022-10-03 N
Assure the security of all personal funds of residents deposited with the facility. Health 2022-08-11 2022-10-03 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 2022-08-11 2022-10-03 N
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Health 2022-08-11 2022-10-03 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 2022-08-11 2022-10-03 N
Assure that each resident?s assessment is updated at least once every 3 months. Health 2022-08-11 2022-10-03 N
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Health 2022-08-11 2022-10-03 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 2022-08-11 2022-10-03 N
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2022-08-11 2022-10-03 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 2022-08-11 2022-10-03 N
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2022-08-11 2022-10-03 N
Provide safe and appropriate respiratory care for a resident when needed. Health 2022-08-11 2022-10-03 N
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. Health 2022-08-11 2022-10-03 N
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Health 2022-08-11 2022-10-03 N
Observe each nurse aide's job performance and give regular training. Health 2022-08-11 2022-10-03 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 2022-08-11 2022-10-03 N
Ensure that residents are free from significant medication errors. Health 2022-08-11 2022-10-03 N
Provide timely, quality laboratory services/tests to meet the needs of residents. Health 2022-08-11 2022-10-03 N
Provide or obtain dental services for each resident. Health 2022-08-11 2022-10-03 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2022-08-11 2022-10-03 N
Provide or get specialized rehabilitative services as required for a resident. Health 2022-08-11 2022-10-03 N
Administer the facility in a manner that enables it to use its resources effectively and efficiently. Health 2022-08-11 2022-10-03 N
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. Health 2022-08-11 2022-10-03 N
Have a plan that describes the process for conducting QAPI and QAA activities. Health 2022-08-11 2022-10-03 N
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Health 2022-08-11 2022-10-03 N
Provide and implement an infection prevention and control program. Health 2022-08-11 2022-10-03 N
Develop and implement policies and procedures for flu and pneumonia vaccinations. Health 2022-08-11 2022-10-03 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 2022-08-11 2022-10-03 N
Make sure that a working call system is available in each resident's bathroom and bathing area. Health 2022-08-11 2022-10-03 N
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Health 2022-08-11 2022-10-03 N
Have enough backup water supply for essential areas of the nursing home. Health 2022-08-11 2022-10-03 N
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. Health 2022-08-11 2022-10-03 N
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Health 2022-08-11 2022-10-03 Y
Develop and implement policies and procedures to prevent abuse, neglect, and theft. Health 2022-08-11 2022-10-03 Y
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. Health 2022-08-11 2022-10-03 Y
Ensure each resident receives an accurate assessment. Health 2022-08-11 2022-10-03 Y
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Health 2022-08-11 2022-10-03 Y
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Health 2022-08-11 2022-10-03 Y
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2022-08-11 2022-10-03 Y
Respond appropriately to all alleged violations. Health 2022-08-11 2022-10-03 Y
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Health 2022-08-11 2022-10-03 Y
Conduct risk assessment and an All-Hazards approach. Fire Safety 2022-08-02 2022-08-31 N
Establish emergency prep training and testing. Fire Safety 2022-08-02 2022-08-31 N
Establish staff and initial training requirements. Fire Safety 2022-08-02 2022-08-31 N
Conduct testing and exercise requirements. Fire Safety 2022-08-02 2022-08-31 N
Have stairways and smokeproof enclosures used as exits that meet safety requirements. Fire Safety 2022-08-02 2022-08-31 N
Provide properly protected cooking facilities. Fire Safety 2022-08-02 2022-08-31 N
Properly provide smoke detection systems in areas open to corridors. Fire Safety 2022-08-02 2022-08-31 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2022-08-02 2022-08-31 N
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. Fire Safety 2022-08-02 2022-08-31 N
Install corridor and hallway doors that block smoke. Fire Safety 2022-08-02 2022-08-31 N
Have simulated fire drills held at unexpected times. Fire Safety 2022-08-02 2022-08-31 N
To conduct inspection, testing and maintenance of fire doors by qualified individuals. Fire Safety 2022-08-02 2022-08-31 N
Meet Health Care Facilities Code mechanical requirements. Fire Safety 2022-08-02 2022-08-31 N
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. Fire Safety 2022-08-02 2022-08-31 N
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2022-08-02 2022-08-31 N
Ensure that testing and maintenance of electrical equipment is performed. Fire Safety 2022-08-02 2022-08-31 N
Have proper medical gas storage and administration areas. Fire Safety 2022-08-02 2022-08-31 N
Ensure services provided by the nursing facility meet professional standards of quality. Health 2022-03-15 2022-06-12 Y
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Health 2022-03-15 2022-06-12 Y
Meet other general requirements. Fire Safety 2019-01-25 2019-03-13 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 2019-01-25 2019-03-13 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 2019-01-25 2019-03-13 N
Provide properly protected cooking facilities. Fire Safety 2019-01-25 2019-03-13 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2019-01-25 2019-03-13 N
Meet fire sprinkler requirement for tall buildings. Fire Safety 2019-01-25 2019-03-13 N
Install properly constructed and protected linen or trash chutes. Fire Safety 2019-01-25 2019-03-13 N
Have simulated fire drills held at unexpected times. Fire Safety 2019-01-25 2019-03-13 N
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2019-01-25 2019-03-13 N
Reasonably accommodate the needs and preferences of each resident. Health 2018-12-21 2019-02-17 N
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2018-12-21 2019-02-17 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2018-12-21 2019-02-17 N
Provide and implement an infection prevention and control program. Health 2018-12-21 2019-02-17 N
Give or get quality laboratory services/tests in a timely manner to meet the needs of residents. Health 2017-08-22 2017-11-13 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 2017-09-13 2017-10-23 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 2017-09-13 2017-10-23 N
Install properly constructed and protected linen or trash chutes. Fire Safety 2017-09-13 2017-10-23 N
Have power receptacles that are properly grounded. Fire Safety 2017-09-13 2017-10-23 N
Have a battery powered remote alarm panel in a location accessible by operating personnel. Fire Safety 2017-09-13 2017-10-23 N
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2017-09-13 2017-10-23 N
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Health 2017-08-22 2017-10-02 N
Protect each resident from all abuse, physical punishment, and involuntary separation from others. Health 2017-08-22 2017-10-02 N
1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. Health 2017-08-22 2017-10-02 N
Provide activities to meet the interests and needs of each resident. Health 2017-08-22 2017-10-02 N
Ensure each resident receives an accurate assessment by a qualified health professional. Health 2017-08-22 2017-10-02 N
Allow residents the right to participate in the planning or revision of care and treatment. Health 2017-08-22 2017-10-02 N
Provide care by qualified persons according to each resident's written plan of care. Health 2017-08-22 2017-10-02 N
Provide necessary care and services to maintain or improve the highest well being of each resident . Health 2017-08-22 2017-10-02 N
Prevent a loss in range of motion among residents who entered the nursing home with a full range of motion, unless it is unavoidable due to resident?s clinical condition. Health 2017-08-22 2017-10-02 N
Ensure that residents with limited range of motion receive appropriate treatment and services to increase range of motion or prevent further decrease in range of motion. Health 2017-08-22 2017-10-02 N
Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Health 2017-08-22 2017-10-02 N
Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. Health 2017-08-22 2017-10-02 N
Have enough nurses to care for every resident in a way that maximizes the resident's well being. Health 2017-08-22 2017-10-02 N
Store, cook, and serve food in a safe and clean way. Health 2017-08-22 2017-10-02 N
Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. Health 2017-08-22 2017-10-02 N
At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor. Health 2017-08-22 2017-10-02 N
Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. Health 2017-08-22 2017-10-02 N
Have a program that investigates, controls and keeps infection from spreading. Health 2017-08-22 2017-10-02 N
Keep all essential equipment working safely. Health 2017-08-22 2017-10-02 N
1) Review the work of each nurse aide every year; and 2) give regular in-service training based upon these reviews. Health 2017-08-22 2017-10-02 N
Make sure that nurse aides show they have the skills and techniques to be able to care for residents' needs. Health 2017-08-22 2017-10-02 N
Keep accurate, complete and organized clinical records on each resident that meet professional standards. Health 2017-08-22 2017-10-02 N
Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action. Health 2017-08-22 2017-10-02 N

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