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Deficiency Records for Autumn Lake Healthcare at Crofton
A list of the most recent deficiencies for Autumn Lake Healthcare at Crofton. 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 Crofton. 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 maintain an Emergency Preparedness Program (EP). | Fire Safety | 2024-02-15 | 2024-04-09 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2024-02-15 | 2024-04-09 | 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 | 2024-02-15 | 2024-04-09 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2024-02-15 | 2024-04-09 | N |
| Have exits that are accessible at all times. | Fire Safety | 2024-02-15 | 2024-04-09 | N |
| Install proper backup exit lighting. | Fire Safety | 2024-02-15 | 2024-04-09 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2024-02-15 | 2024-04-09 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2024-02-15 | 2024-04-09 | 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 | 2024-02-15 | 2024-04-09 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-02-15 | 2024-04-09 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2024-02-15 | 2024-04-09 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-02-15 | 2024-04-09 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2024-02-15 | 2024-04-09 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-02-15 | 2024-04-09 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2024-02-15 | 2024-04-09 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2024-02-15 | 2024-04-09 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2024-02-15 | 2024-04-09 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-02-15 | 2024-04-09 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2024-02-15 | 2024-04-09 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-02-15 | 2024-04-09 | N |
| Provide properly sized and located linen or trash receptacles. | Fire Safety | 2024-02-15 | 2024-04-09 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2024-02-15 | 2024-04-09 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-02-15 | 2024-04-09 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2024-02-15 | 2024-04-09 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2024-02-20 | 2024-04-04 | N |
| Assure the security of all personal funds of residents deposited with the facility. | Health | 2024-02-20 | 2024-04-04 | 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 | 2024-02-20 | 2024-04-04 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-02-20 | 2024-04-04 | 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 | 2024-02-20 | 2024-04-04 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-02-20 | 2024-04-04 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-02-20 | 2024-04-04 | 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 | 2024-02-20 | 2024-04-04 | 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 | 2024-02-20 | 2024-04-04 | 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 | 2024-02-20 | 2024-04-04 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-02-20 | 2024-04-04 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-02-20 | 2024-04-04 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-02-20 | 2024-04-04 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-03-25 | 2019-04-26 | 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 | 2019-03-25 | 2019-04-26 | 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 | 2019-03-25 | 2019-04-26 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-03-25 | 2019-04-26 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-03-20 | 2019-04-16 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2019-03-20 | 2019-04-16 | 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 | 2019-03-20 | 2019-04-01 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-03-20 | 2019-03-27 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-03-20 | 2019-03-27 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-03-20 | 2019-03-27 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-03-20 | 2019-03-23 | N |
| Meet other general requirements. | Fire Safety | 2019-03-20 | 2019-03-22 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2019-03-20 | 2019-03-21 | N |
| Have exits that are accessible at all times. | Fire Safety | 2017-11-14 | 2018-02-08 | N |
| Let residents refuse treatment, refuse to take part in an experiment, or formulate advance directives. | Health | 2017-11-09 | 2018-01-09 | N |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2017-11-09 | 2018-01-09 | 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 | 2017-11-09 | 2018-01-09 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2017-11-09 | 2018-01-09 | N |
| Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2017-11-09 | 2018-01-09 | N |
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