Deficiency Records for Autumn Lake Healthcare at Patuxent River
Updated as of March 01, 2024
A list of the most recent deficiencies for Autumn Lake Healthcare at Patuxent River. 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 | 2022-05-10 | 2022-08-12 | 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 | 2022-05-10 | 2022-08-12 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2022-05-10 | 2022-08-12 | N |
| Have exits that are accessible at all times. | Fire Safety | 2022-05-10 | 2022-08-12 | 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 | 2022-05-10 | 2022-08-12 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-05-10 | 2022-08-12 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-05-10 | 2022-08-12 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-05-10 | 2022-08-12 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-05-10 | 2022-08-12 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-05-10 | 2022-08-12 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-05-10 | 2022-08-12 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-05-06 | 2022-08-01 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-05-06 | 2022-08-01 | 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 | 2022-05-06 | 2022-08-01 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-05-06 | 2022-08-01 | 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 | 2022-05-06 | 2022-08-01 | N |
| Ensure that residents are free from significant medication errors. | Health | 2022-05-06 | 2022-08-01 | 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 | 2022-05-06 | 2022-08-01 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-05-06 | 2022-08-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-05-06 | 2022-08-01 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-05-06 | 2022-08-01 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-05-06 | 2022-08-01 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-05-06 | 2022-08-01 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-05-06 | 2022-08-01 | 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 | 2022-05-06 | 2022-08-01 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-05-06 | 2022-08-01 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-05-06 | 2022-08-01 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-05-06 | 2022-08-01 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-05-06 | 2022-08-01 | Y |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-05-10 | 2022-06-24 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2022-05-10 | 2022-06-24 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-05-10 | 2022-06-24 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2022-05-10 | 2022-06-24 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2022-05-10 | 2022-06-24 | N |
| Meet requirements for operating features, such as evacuation plans, fire drills, smoking regulations, draperies, decorations and the inspection, testing and maintenance of fire doors. | Fire Safety | 2022-05-10 | 2022-06-24 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-05-10 | 2022-06-24 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2022-05-10 | 2022-06-24 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2022-05-10 | 2022-06-24 | N |
| Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | Fire Safety | 2022-05-10 | 2022-06-24 | N |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2021-10-19 | 2021-12-14 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-10-19 | 2021-12-14 | Y |
| 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 | 2021-10-19 | 2021-12-14 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-10-19 | 2021-12-14 | 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 | 2021-10-19 | 2021-12-14 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-10-19 | 2021-12-14 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2021-10-19 | 2021-12-14 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2021-10-19 | 2021-12-14 | Y |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2021-10-19 | 2021-12-14 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-10-19 | 2021-12-14 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-10-19 | 2021-12-14 | Y |
| Provide appropriate foot care. | Health | 2021-10-19 | 2021-12-14 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-10-19 | 2021-12-14 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-10-19 | 2021-12-14 | Y |
| 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 | 2021-10-19 | 2021-12-14 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-10-19 | 2021-12-14 | Y |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2021-10-19 | 2021-12-14 | 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 | 2021-10-19 | 2021-12-14 | Y |
| 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 | 2021-10-19 | 2021-12-14 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-10-19 | 2021-12-14 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-10-19 | 2021-12-14 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-10-19 | 2021-12-14 | Y |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2021-10-19 | 2021-12-14 | Y |
| Address patient/client population and determine types of services needed. | Fire Safety | 2021-10-19 | 2021-12-14 | Y |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2021-10-19 | 2021-12-14 | Y |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2021-10-19 | 2021-12-14 | Y |
| Address subsistence needs for staff and patients. | Fire Safety | 2021-10-19 | 2021-12-14 | Y |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2021-10-19 | 2021-12-14 | Y |
| Establish policies and procedures including evacuation. | Fire Safety | 2021-10-19 | 2021-12-14 | Y |
| Establish policies and procedures for sheltering. | Fire Safety | 2021-10-19 | 2021-12-14 | Y |
| Establish policies and procedures for medical documentation. | Fire Safety | 2021-10-19 | 2021-12-14 | Y |
| Establish policies and procedures for volunteers. | Fire Safety | 2021-10-19 | 2021-12-14 | Y |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2021-10-19 | 2021-12-14 | Y |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2021-10-19 | 2021-12-14 | Y |
| Develop a communication plan. | Fire Safety | 2021-10-19 | 2021-12-14 | Y |
| List the names and contact information of those in the facility. | Fire Safety | 2021-10-19 | 2021-12-14 | Y |
| Provide emergency officials' contact information. | Fire Safety | 2021-10-19 | 2021-12-14 | Y |
| Provide primary/alternate means for communication. | Fire Safety | 2021-10-19 | 2021-12-14 | Y |
| Establish methods for sharing information. | Fire Safety | 2021-10-19 | 2021-12-14 | Y |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2021-10-19 | 2021-12-14 | Y |
| Provide family notifications of emergency plan. | Fire Safety | 2021-10-19 | 2021-12-14 | Y |
| Establish emergency prep training and testing. | Fire Safety | 2021-10-19 | 2021-12-14 | Y |
| Establish staff and initial training requirements. | Fire Safety | 2021-10-19 | 2021-12-14 | Y |
| Conduct testing and exercise requirements. | Fire Safety | 2021-10-19 | 2021-12-14 | Y |
| Implement emergency and standby power systems. | Fire Safety | 2021-10-19 | 2021-12-14 | Y |
| Meet the requirements of an integrated health system. | Fire Safety | 2021-10-19 | 2021-12-14 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-09-19 | 2018-10-31 | 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 | 2018-09-19 | 2018-10-31 | 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 | 2018-09-19 | 2018-10-31 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-09-19 | 2018-10-31 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2018-09-19 | 2018-10-31 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2018-09-19 | 2018-10-31 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-09-19 | 2018-10-31 | N |
| Provide activities to meet all resident's needs. | Health | 2018-09-19 | 2018-10-31 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-09-19 | 2018-10-31 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-09-19 | 2018-10-31 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2018-09-19 | 2018-10-31 | 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 | 2018-09-19 | 2018-10-31 | N |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2018-09-19 | 2018-10-31 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-09-19 | 2018-10-31 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-09-19 | 2018-10-31 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2018-09-19 | 2018-10-31 | N |
| Put firmly secured handrails on each side of hallways. | Health | 2018-09-19 | 2018-10-31 | N |
| Give notice to the resident before a room or roommate change. | Health | 2017-05-30 | 2017-07-13 | N |
| Provide housekeeping and maintenance services. | Health | 2017-05-30 | 2017-07-13 | N |
| Conduct initial and periodic assessments of each resident's functional capacity. | Health | 2017-05-30 | 2017-07-13 | N |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2017-05-30 | 2017-07-13 | N |
| Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. | Health | 2017-05-30 | 2017-07-13 | N |
| Give each resident enough fluids to keep them healthy and prevent dehydration. | Health | 2017-05-30 | 2017-07-13 | N |
| Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2017-05-30 | 2017-07-13 | N |
| Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service. | Health | 2017-05-30 | 2017-07-13 | N |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2017-05-30 | 2017-07-13 | 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 | 2017-05-19 | 2017-05-22 | N |
