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Deficiency Records for Autumn Lake Healthcare at Calvert Manor

View the most recent health deficiencies and inspection results for Autumn Lake Healthcare at Calvert Manor. Stay informed about quality of care issues.

View the most recent health deficiencies and inspection results for Autumn Lake Healthcare at Calvert Manor. Stay informed about quality of care issues.

Deficiency Type of Deficiency Deficiency Date Date Corrected Resulted from a Complaint?
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Health 2025-12-10 2026-01-10 Y
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2025-12-10 2026-01-10 Y
Keep aisles, corridors, and exits free of obstruction in case of emergency. Fire Safety 2025-04-02 2025-05-29 N
Meet other general requirements. Fire Safety 2025-04-02 2025-05-29 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 2025-04-02 2025-05-29 N
Install properly constructed and protected linen or trash chutes. Fire Safety 2025-04-02 2025-05-29 N
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. Fire Safety 2025-04-02 2025-05-29 N
Have properly installed electrical wiring and gas equipment. Fire Safety 2025-04-02 2025-05-29 N
Properly select, install, inspect, or maintain portable fire extinguishes. Fire Safety 2025-04-02 2025-05-29 N
Install an approved automatic sprinkler system. Fire Safety 2025-04-02 2025-05-29 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 2025-04-02 2025-05-29 N
Provide sliding doors free of hazards, operable without special knowledge or effort, and meet weight requirements to set door in motion. Fire Safety 2025-04-02 2025-05-29 N
Have exits that are accessible at all times. Fire Safety 2025-04-02 2025-05-29 N
Have properly located and lighted "Exit" signs. Fire Safety 2025-04-02 2025-05-29 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 2025-04-02 2025-05-29 N
Install a fire alarm system that can be heard throughout the facility. Fire Safety 2025-04-02 2025-05-29 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2025-04-02 2025-05-29 N
Keep residents' personal and medical records private and confidential. Health 2025-04-02 2025-05-09 N
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2025-04-02 2025-05-09 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 2025-04-02 2025-05-09 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 2025-04-02 2025-05-09 N
Provide safe and appropriate respiratory care for a resident when needed. Health 2025-04-02 2025-05-09 N
Provide safe, appropriate pain management for a resident who requires such services. Health 2025-04-02 2025-05-09 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 2025-04-02 2025-05-09 N
Ensure each resident?s drug regimen must be free from unnecessary drugs. Health 2025-04-02 2025-05-09 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 2025-04-02 2025-05-09 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 2025-04-02 2025-05-09 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 2025-04-02 2025-05-09 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2025-04-02 2025-05-09 N
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Health 2025-04-02 2025-05-09 N
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. Health 2025-04-02 2025-05-09 Y
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2025-04-02 2025-05-09 Y
Respond appropriately to all alleged violations. Health 2025-04-02 2025-05-09 Y
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2025-04-02 2025-05-09 Y
Observe each nurse aide's job performance and give regular training. Health 2025-04-02 2025-05-09 Y
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Health 2025-04-02 2025-05-09 Y
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. Health 2025-04-02 2025-05-09 Y
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 2025-04-02 2025-05-09 Y
Have proper medical gas storage and administration areas. Fire Safety 2022-10-18 2022-12-30 N
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2022-10-18 2022-12-30 N
Install proper backup exit lighting. Fire Safety 2022-10-18 2022-12-30 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 2022-10-18 2022-12-30 N
Provide properly protected cooking facilities. Fire Safety 2022-10-18 2022-12-30 N
Have approved installation, maintenance and testing program for fire alarm systems. Fire Safety 2022-10-18 2022-12-30 N
Properly install and monitor supervisory attachments on automatic sprinkler systems. Fire Safety 2022-10-18 2022-12-30 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2022-10-18 2022-12-30 N
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. Fire Safety 2022-10-18 2022-12-30 N
Install corridor and hallway doors that block smoke. Fire Safety 2022-10-18 2022-12-30 N
Install smoke barrier doors that can resist smoke for at least 20 minutes. Fire Safety 2022-10-18 2022-12-30 N
Have properly installed electrical wiring and gas equipment. Fire Safety 2022-10-18 2022-12-30 N
Enure that solid fuel-burning fireplaces are not in patient sleeping areas. Fire Safety 2022-10-18 2022-12-30 N
Install properly constructed and protected linen or trash chutes. Fire Safety 2022-10-18 2022-12-30 N
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. Fire Safety 2022-10-18 2022-12-30 N
To conduct inspection, testing and maintenance of fire doors by qualified individuals. Fire Safety 2022-10-18 2022-12-30 N
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. Fire Safety 2022-10-18 2022-12-30 N
Have a battery powered remote alarm panel in a location accessible by operating personnel. Fire Safety 2022-10-18 2022-12-30 N
Meet other general requirements that are deficient. Fire Safety 2022-10-18 2022-12-30 N
Have exits that are accessible at all times. Fire Safety 2018-12-17 2019-02-18 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2018-12-17 2019-01-31 N
Provide timely, quality laboratory services/tests to meet the needs of residents. Health 2018-12-17 2019-01-31 N
Provide enough food/fluids to maintain a resident's health. Health 2018-12-17 2019-01-31 N
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2018-12-17 2019-01-31 N
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2018-12-17 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 2018-12-17 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 2018-12-17 2019-01-31 N
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. Health 2018-12-17 2019-01-31 N
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. Health 2018-12-17 2019-01-31 N

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