Deficiency Records for Autumn Lake Healthcare at Catonsville
Updated as of April 01, 2024
A list of the most recent deficiencies for Autumn Lake Healthcare at Catonsville. 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 aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-08-21 | 2023-09-18 | Y |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-08-21 | 2023-09-18 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-03-24 | 2023-05-08 | N |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2023-03-24 | 2023-05-08 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-03-24 | 2023-05-08 | N |
| Give residents a notice of rights, rules, services and charges. | Health | 2023-03-24 | 2023-05-08 | 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 | 2023-03-24 | 2023-05-08 | N |
| Respond appropriately to all alleged violations. | Health | 2023-03-24 | 2023-05-08 | 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 | 2023-03-24 | 2023-05-08 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2023-03-24 | 2023-05-08 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-03-24 | 2023-05-08 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-03-24 | 2023-05-08 | 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 | 2023-03-24 | 2023-05-08 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-03-24 | 2023-05-08 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-03-24 | 2023-05-08 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-24 | 2023-05-08 | N |
| 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 | 2023-03-24 | 2023-05-08 | N |
| Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. | Health | 2023-03-24 | 2023-05-08 | N |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2023-03-24 | 2023-05-08 | N |
| Post nurse staffing information every day. | Health | 2023-03-24 | 2023-05-08 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-03-24 | 2023-05-08 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-03-24 | 2023-05-08 | 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 | 2023-03-24 | 2023-05-08 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2023-03-24 | 2023-05-08 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-03-24 | 2023-05-08 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-03-24 | 2023-05-08 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-03-24 | 2023-05-08 | N |
| Provide at least one room set aside to use as a resident dining room and for activities, that is a good size, with good lighting, air flow and furniture. | Health | 2023-03-24 | 2023-05-08 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-03-24 | 2023-05-08 | N |
| 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 | 2023-03-24 | 2023-05-08 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2023-03-24 | 2023-05-08 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-03-24 | 2023-05-08 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-03-21 | 2023-04-19 | N |
| Install proper backup exit lighting. | Fire Safety | 2023-03-21 | 2023-04-19 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-03-21 | 2023-04-19 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-03-21 | 2023-04-19 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-03-21 | 2023-04-19 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2023-03-21 | 2023-04-19 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-03-21 | 2023-04-19 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-03-21 | 2023-04-19 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-03-21 | 2023-04-19 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-03-21 | 2023-04-19 | N |
| Post nurse staffing information every day. | Health | 2022-01-20 | 2022-03-22 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-01-20 | 2022-03-22 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-01-20 | 2022-03-22 | Y |
| 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 | 2022-01-20 | 2022-03-22 | Y |
| Meet other general requirements. | Fire Safety | 2019-02-28 | 2019-04-05 | N |
| Meet other general requirements. | Fire Safety | 2019-02-28 | 2019-04-05 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-02-28 | 2019-04-05 | 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 | 2019-02-28 | 2019-04-05 | 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 | 2019-02-28 | 2019-04-05 | N |
| Have exits that are accessible at all times. | Fire Safety | 2019-02-28 | 2019-04-05 | N |
| Install proper backup exit lighting. | Fire Safety | 2019-02-28 | 2019-04-05 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-02-28 | 2019-04-05 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-02-28 | 2019-04-05 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-02-28 | 2019-04-05 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-02-28 | 2019-04-05 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2019-02-28 | 2019-04-05 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-12-21 | 2019-01-31 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2018-12-21 | 2019-01-31 | 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 | 2018-12-21 | 2019-01-31 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2018-12-21 | 2019-01-31 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2018-12-21 | 2019-01-31 | N |
| 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 | 2018-12-21 | 2019-01-31 | N |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2018-12-21 | 2019-01-31 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-12-21 | 2019-01-31 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2018-12-21 | 2019-01-31 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-12-21 | 2019-01-31 | 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 | 2018-12-21 | 2019-01-31 | N |
| Honor each resident's preferences, choices, values and beliefs. | Health | 2018-12-21 | 2019-01-31 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-12-21 | 2019-01-31 | 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 | 2018-12-21 | 2019-01-31 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-12-21 | 2019-01-31 | N |
| 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 | 2018-12-21 | 2019-01-31 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2018-12-21 | 2019-01-31 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2018-12-21 | 2019-01-31 | 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 | 2018-12-21 | 2019-01-31 | N |
| Ensure that residents are free from significant medication errors. | Health | 2018-12-21 | 2019-01-31 | 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 | 2018-12-21 | 2019-01-31 | 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 | 2018-12-21 | 2019-01-31 | 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 | 2018-12-21 | 2019-01-31 | 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 | 2019-01-31 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-12-21 | 2019-01-31 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2018-12-21 | 2019-01-31 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-12-21 | 2019-01-31 | N |
| Keep all essential equipment working safely. | Health | 2018-12-21 | 2019-01-31 | N |
| Have enough backup water supply for essential areas of the nursing home. | Health | 2018-12-21 | 2019-01-31 | N |
| Ensure each resident receives an accurate assessment by a qualified health professional. | Health | 2017-09-08 | 2017-10-30 | N |
| Allow residents the right to participate in the planning or revision of care and treatment. | Health | 2017-09-08 | 2017-10-30 | N |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2017-09-08 | 2017-10-30 | 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 | 2017-09-08 | 2017-10-30 | N |
| Ensure that residents are safe from serious medication errors. | Health | 2017-09-08 | 2017-10-30 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2017-09-08 | 2017-10-30 | N |
| Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. | Health | 2017-09-08 | 2017-10-30 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2017-09-08 | 2017-10-30 | N |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2017-09-08 | 2017-10-30 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action. | Health | 2017-09-08 | 2017-10-30 | N |
| Meet other general requirements. | Fire Safety | 2017-10-04 | 2017-10-29 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2017-10-04 | 2017-10-29 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2017-10-04 | 2017-10-29 | N |
| Have an externally vented heating system. | Fire Safety | 2017-10-04 | 2017-10-29 | N |
