Deficiency Records for Autumn Lake Healthcare at Pikesville
Updated as of March 01, 2024
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 |
| Keep residents' personal and medical records private and confidential. | Health | 2021-07-29 | 2021-10-15 | Y |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2021-07-29 | 2021-10-15 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-07-29 | 2021-10-15 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2021-07-29 | 2021-10-15 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-07-29 | 2021-10-15 | Y |
| 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 | 2021-07-29 | 2021-10-15 | Y |
| Post nurse staffing information every day. | Health | 2021-07-29 | 2021-10-15 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-07-29 | 2021-10-15 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-07-29 | 2021-10-15 | 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 |
