Deficiency Records for Autumn Lake Healthcare at Calvert Manor
Updated as of April 01, 2024
A list of the most recent deficiencies for Autumn Lake Healthcare at Calvert Manor. 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? |
|---|---|---|---|---|
| Install proper backup exit lighting. | Fire Safety | 2022-10-19 | 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 | 2022-10-19 | 2022-12-30 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-10-19 | 2022-12-30 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-10-19 | 2022-12-30 | N |
| Properly install and monitor supervisory attachments on automatic sprinkler systems. | Fire Safety | 2022-10-19 | 2022-12-30 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-10-19 | 2022-12-30 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2022-10-19 | 2022-12-30 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-10-19 | 2022-12-30 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-10-19 | 2022-12-30 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2022-10-19 | 2022-12-30 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-10-19 | 2022-12-30 | N |
| Enure that solid fuel-burning fireplaces are not in patient sleeping areas. | Fire Safety | 2022-10-19 | 2022-12-30 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2022-10-19 | 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 | 2022-10-19 | 2022-12-30 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-10-19 | 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 | 2022-10-19 | 2022-12-30 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2022-10-19 | 2022-12-30 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-10-19 | 2022-12-30 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-10-19 | 2022-12-30 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2022-07-12 | 2022-08-12 | Y |
| Have exits that are accessible at all times. | Fire Safety | 2019-01-03 | 2019-02-18 | 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 |
| 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 |
| 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 |
| 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 |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | 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 enough food/fluids to maintain a resident's health. | 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 |
| 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 |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2017-09-28 | 2017-11-17 | N |
| Install proper backup exit lighting. | Fire Safety | 2017-09-28 | 2017-11-17 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2017-09-28 | 2017-11-17 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2017-09-28 | 2017-11-17 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2017-09-28 | 2017-11-17 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2017-09-28 | 2017-11-17 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2017-09-28 | 2017-11-17 | N |
| Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2017-09-08 | 2017-10-23 | N |
| Keep all essential equipment working safely. | Health | 2017-09-08 | 2017-10-23 | N |
