Deficiency Records for Autumn Lake Healthcare at Loch Raven
Updated as of March 01, 2024
A list of the most recent deficiencies for Autumn Lake Healthcare at Loch Raven. 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? |
|---|---|---|---|---|
| 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 | 2023-09-06 | 2023-10-17 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-09-06 | 2023-10-17 | Y |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2023-06-07 | 2023-09-30 | 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 | 2023-06-07 | 2023-09-30 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-06-07 | 2023-09-30 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2023-06-07 | 2023-09-30 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-06-07 | 2023-09-30 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-06-07 | 2023-09-30 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-06-07 | 2023-09-30 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-06-07 | 2023-09-30 | N |
| Use approved construction type or materials. | Fire Safety | 2023-06-07 | 2023-08-01 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-06-07 | 2023-08-01 | 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 | 2023-06-07 | 2023-08-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-06-07 | 2023-08-01 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-06-07 | 2023-08-01 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-06-07 | 2023-08-01 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-06-07 | 2023-08-01 | N |
| Provide properly sized and located linen or trash receptacles. | Fire Safety | 2023-06-07 | 2023-08-01 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-06-07 | 2023-08-01 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2023-06-07 | 2023-08-01 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-06-07 | 2023-08-01 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-06-07 | 2023-08-01 | N |
| Respond appropriately to all alleged violations. | Health | 2023-06-13 | 2023-07-14 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-06-13 | 2023-07-14 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-06-13 | 2023-07-14 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-06-13 | 2023-07-14 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-06-13 | 2023-07-14 | 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 | 2023-06-13 | 2023-07-14 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-06-13 | 2023-07-14 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-06-13 | 2023-07-14 | 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 | 2023-06-13 | 2023-07-14 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-06-13 | 2023-07-14 | N |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2023-06-13 | 2023-07-14 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2023-06-13 | 2023-07-14 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-06-13 | 2023-07-14 | N |
| Implement a program that monitors antibiotic use. | Health | 2023-06-13 | 2023-07-14 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-06-13 | 2023-07-14 | Y |
| Assist a resident in gaining access to vision and hearing services. | Health | 2023-06-13 | 2023-07-14 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-06-13 | 2023-07-14 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-08-26 | 2021-11-26 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-08-26 | 2021-11-26 | Y |
| Provide properly sized and located linen or trash receptacles. | Fire Safety | 2019-03-04 | 2019-03-21 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2019-03-04 | 2019-03-21 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-01-10 | 2019-03-01 | N |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2019-01-10 | 2019-03-01 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-01-10 | 2019-03-01 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2019-01-10 | 2019-03-01 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-01-10 | 2019-03-01 | 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 | 2019-01-10 | 2019-03-01 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-01-10 | 2019-03-01 | N |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2019-01-10 | 2019-03-01 | 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 | 2019-01-10 | 2019-03-01 | N |
| Assess the resident when there is a significant change in condition | Health | 2019-01-10 | 2019-03-01 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-01-10 | 2019-03-01 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-01-10 | 2019-03-01 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-01-10 | 2019-03-01 | 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 | 2019-01-10 | 2019-03-01 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-01-10 | 2019-03-01 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-01-10 | 2019-03-01 | N |
| Provide activities to meet all resident's needs. | Health | 2019-01-10 | 2019-03-01 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-01-10 | 2019-03-01 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2019-01-10 | 2019-03-01 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-01-10 | 2019-03-01 | 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 | 2019-01-10 | 2019-03-01 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-01-10 | 2019-03-01 | 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 | 2019-01-10 | 2019-03-01 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-01-10 | 2019-03-01 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-01-10 | 2019-03-01 | 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 | 2019-01-10 | 2019-03-01 | 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 | 2019-01-10 | 2019-03-01 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2019-01-10 | 2019-03-01 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-01-10 | 2019-03-01 | 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 | 2019-01-10 | 2019-03-01 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-01-10 | 2019-03-01 | 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 | 2019-01-10 | 2019-03-01 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-01-10 | 2019-03-01 | N |
| Ensure that residents are free from significant medication errors. | Health | 2019-01-10 | 2019-03-01 | 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 | 2019-01-10 | 2019-03-01 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2019-01-10 | 2019-03-01 | 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 | 2019-01-10 | 2019-03-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-01-10 | 2019-03-01 | 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 | 2019-01-10 | 2019-03-01 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-01-10 | 2019-03-01 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2019-01-10 | 2019-03-01 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-01-10 | 2019-03-01 | 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 | 2019-01-10 | 2019-03-01 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2017-08-31 | 2017-10-13 | N |
| Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. | Health | 2017-08-31 | 2017-10-13 | N |
| Ensure each resident receives an accurate assessment by a qualified health professional. | Health | 2017-08-31 | 2017-10-13 | N |
| Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2017-08-31 | 2017-10-13 | N |
| Allow residents the right to participate in the planning or revision of care and treatment. | Health | 2017-08-31 | 2017-10-13 | N |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2017-08-31 | 2017-10-13 | N |
| Ensure residents maintain acceptable nutritional status. | Health | 2017-08-31 | 2017-10-13 | 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 | 2017-08-31 | 2017-10-13 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2017-08-31 | 2017-10-13 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2017-08-31 | 2017-10-13 | N |
| Give or get quality laboratory services/tests in a timely manner to meet the needs of residents. | Health | 2017-08-31 | 2017-10-13 | N |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2017-08-31 | 2017-10-13 | N |
