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Deficiency Records for Autumn Lake Healthcare at Baltimore Washington
A list of the most recent deficiencies for Autumn Lake Healthcare at Baltimore Washington. 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 Baltimore Washington. 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? |
|---|---|---|---|---|
| Keep residents' personal and medical records private and confidential. | Health | 2024-09-09 | 2024-10-23 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-09-09 | 2024-10-23 | Y |
| Respond appropriately to all alleged violations. | Health | 2024-09-09 | 2024-10-23 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2024-09-09 | 2024-10-23 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-09-09 | 2024-10-23 | 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 | 2024-09-09 | 2024-10-23 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2024-09-09 | 2024-10-23 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-09-09 | 2024-10-23 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2024-09-09 | 2024-10-23 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2024-09-09 | 2024-10-23 | 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 | 2024-09-09 | 2024-10-23 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2024-09-09 | 2024-10-23 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-09-09 | 2024-10-23 | 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 | 2024-09-09 | 2024-10-23 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2024-09-09 | 2024-10-23 | 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 | 2024-09-09 | 2024-10-23 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2024-09-09 | 2024-10-23 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-09-09 | 2024-10-23 | N |
| Put firmly secured handrails on each side of hallways. | Health | 2024-09-09 | 2024-10-23 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-09-09 | 2024-10-23 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-09-09 | 2024-10-23 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2024-09-09 | 2024-10-23 | Y |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2024-09-09 | 2024-10-23 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-09-09 | 2024-10-23 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-09-09 | 2024-10-23 | Y |
| 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 | 2024-09-09 | 2024-10-23 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-09-09 | 2024-10-23 | 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 | 2024-09-09 | 2024-10-23 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-09-09 | 2024-10-23 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2024-09-09 | 2024-10-23 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2024-09-04 | 2024-10-17 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2024-09-04 | 2024-10-17 | 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 | 2024-09-04 | 2024-10-17 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2024-09-04 | 2024-10-17 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2024-09-04 | 2024-10-17 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2024-09-04 | 2024-10-17 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-09-04 | 2024-10-17 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2024-09-04 | 2024-10-17 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2024-09-04 | 2024-10-17 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-09-04 | 2024-10-17 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-09-04 | 2024-10-17 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2024-09-04 | 2024-10-17 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2024-09-04 | 2024-10-17 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-09-04 | 2024-10-17 | N |
| Respond appropriately to all alleged violations. | Health | 2019-10-15 | 2019-11-25 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-10-15 | 2019-11-25 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-10-15 | 2019-11-25 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-10-15 | 2019-11-25 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2019-10-15 | 2019-11-25 | N |
| Provide activities to meet all resident's needs. | Health | 2019-10-15 | 2019-11-25 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-10-15 | 2019-11-25 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-10-15 | 2019-11-25 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-10-15 | 2019-11-25 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-10-15 | 2019-11-25 | N |
| Provide or obtain dental services for each resident. | Health | 2019-10-15 | 2019-11-25 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-10-15 | 2019-11-25 | N |
| Have enough outside ventilation via a window or mechanical ventilation, or both. | Health | 2019-10-15 | 2019-11-25 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2019-10-15 | 2019-11-25 | 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 | 2019-10-08 | 2019-11-22 | N |
| Have correct number of accessible exits for each story. | Fire Safety | 2019-10-08 | 2019-11-22 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-10-08 | 2019-11-22 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-10-08 | 2019-11-22 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-10-08 | 2019-11-22 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-05-01 | 2018-06-15 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2018-05-01 | 2018-06-15 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2018-05-01 | 2018-06-15 | 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 | 2018-05-01 | 2018-06-15 | N |
| 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 | 2018-05-01 | 2018-06-15 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2018-05-01 | 2018-06-15 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-05-01 | 2018-06-15 | 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 | 2018-05-01 | 2018-06-15 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-05-01 | 2018-06-15 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-05-01 | 2018-06-15 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2018-05-01 | 2018-06-15 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2018-05-01 | 2018-06-15 | N |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2018-05-01 | 2018-06-15 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2018-05-01 | 2018-06-15 | 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 | 2018-05-01 | 2018-06-15 | N |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2018-05-01 | 2018-06-15 | N |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2018-05-01 | 2018-06-15 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-05-01 | 2018-06-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-05-01 | 2018-06-15 | N |
| Have exits that are accessible at all times. | Fire Safety | 2018-04-26 | 2018-05-31 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-04-26 | 2018-05-31 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2018-04-26 | 2018-05-31 | N |
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