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Autumn Lake Healthcare At Summit Park

Inspection Results

Nursing Homes Maryland Catonsville Autumn Lake Healthcare At Summit Park

Autumn Lake Healthcare At Summit Park has been cited for a total of 152 deficiencies since we began saving each survey. We believe it is worthwhile to show how things are and were. Some improve and some get worse. Rather than a snapshot, we take s longer view than most. A longer view, we believe, paints a better and more worthwhile picture. We start from them most recent and go back as you scroll down.

Tip: Surveys happen throughout the year and you may want to check with the location or here to see if more recent data is available for Autumn Lake Healthcare At Summit Park.

Since we bagan longer term (multi year tracking, numbers will naturally be higher than 3 (or so surverys).
There are 238 nursing homes in Maryland with a total of 18,830 deficiencies resulting in an average of 79.12 deficiencies per nursing home.

The following table describes how deficiencies are scored. An easy way to remember the severity of a deficiency's scope is that the further along in the alphabet (A through L) the scope value is, the more severe the deficiency is.
Additionally, A through F means no actual harm has happened.

Table describing the severity and scope of deficiencies

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Deficiency Cited, Scope, survery date, stems from a complaint, and Date of Correction
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Category:
Resident Rights Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2021-03-19
Corrected:
2021-05-07
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.
Category:
Resident Rights Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2021-03-19
Corrected:
2021-05-07
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2021-03-19
Corrected:
2021-05-07
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
E
From Complaint:
Y
Standard:
N
Survey Date:
2021-03-19
Corrected:
2021-05-07
Ensure services provided by the nursing facility meet professional standards of quality.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2021-03-19
Corrected:
2021-05-07
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2021-03-19
Corrected:
2021-05-07
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Category:
Quality of Life and Care Deficiencies
Scope:
E
From Complaint:
Y
Standard:
N
Survey Date:
2021-03-19
Corrected:
2021-05-07
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.
Category:
Nursing and Physician Services Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2021-03-19
Corrected:
2021-05-07
Post nurse staffing information every day.
Category:
Nursing and Physician Services Deficiencies
Scope:
C
From Complaint:
Y
Standard:
N
Survey Date:
2021-03-19
Corrected:
2021-05-07
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Category:
Pharmacy Service Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2021-03-19
Corrected:
2021-05-07
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Category:
Administration Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2021-03-19
Corrected:
2021-05-07
Provide and implement an infection prevention and control program.
Category:
Infection Control Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2021-03-19
Corrected:
2021-05-07
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Category:
Resident Rights Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2021-03-19
Corrected:
2021-05-07
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.
Category:
Resident Rights Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2021-03-19
Corrected:
2021-05-07
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2021-03-19
Corrected:
2021-05-07
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
E
From Complaint:
Y
Standard:
N
Survey Date:
2021-03-19
Corrected:
2021-05-07
Ensure services provided by the nursing facility meet professional standards of quality.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2021-03-19
Corrected:
2021-05-07
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2021-03-19
Corrected:
2021-05-07
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Category:
Quality of Life and Care Deficiencies
Scope:
E
From Complaint:
Y
Standard:
N
Survey Date:
2021-03-19
Corrected:
2021-05-07
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.
Category:
Nursing and Physician Services Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2021-03-19
Corrected:
2021-05-07
Post nurse staffing information every day.
Category:
Nursing and Physician Services Deficiencies
Scope:
C
From Complaint:
Y
Standard:
N
Survey Date:
2021-03-19
Corrected:
2021-05-07
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Category:
Pharmacy Service Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2021-03-19
Corrected:
2021-05-07
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Category:
Administration Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2021-03-19
Corrected:
2021-05-07
Provide and implement an infection prevention and control program.
Category:
Infection Control Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2021-03-19
Corrected:
2021-05-07
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.
Category:
Pharmacy Service Deficiencies
Scope:
D
From Complaint:
N
Standard:
N
Survey Date:
2020-12-08
Corrected:
2021-01-15
Provide and implement an infection prevention and control program.
Category:
Infection Control Deficiencies
Scope:
D
From Complaint:
N
Standard:
N
Survey Date:
2020-12-08
Corrected:
2021-01-15
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Category:
Resident Rights Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-03-21
Corrected:
2019-05-21
Ensure that residents are fully informed and understand their health status, care and treatments.
Category:
Resident Rights Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-03-21
Corrected:
2019-07-30
Reasonably accommodate the needs and preferences of each resident.
Category:
Resident Rights Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-03-21
Corrected:
2019-05-21
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Category:
Resident Rights Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-03-21
Corrected:
2019-05-21
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Category:
Resident Rights Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-03-21
Corrected:
2019-05-21
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.
Category:
Resident Rights Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-03-21
Corrected:
2019-05-21
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Category:
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-03-21
Corrected:
2019-05-21
Ensure that each resident is free from medications that restrain them, unless needed for medical treatment.
Category:
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-03-21
Corrected:
2019-05-21
Respond appropriately to all alleged violations.
Category:
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-03-21
Corrected:
2019-05-21
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Category:
Resident Rights Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-03-21
Corrected:
2019-05-21
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.
Category:
Resident Rights Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-03-21
Corrected:
2019-05-21
Ensure each resident receives an accurate assessment.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-03-21
Corrected:
2019-05-21
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-03-21
Corrected:
2019-07-30
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-03-21
Corrected:
2019-07-30
Provide activities to meet all resident's needs.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-03-21
Corrected:
2019-05-21
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-03-21
Corrected:
2019-07-30
Assist a resident in gaining access to vision and hearing services.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-03-21
Corrected:
2019-05-21
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-03-21
Corrected:
2019-05-21
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category:
Quality of Life and Care Deficiencies
Scope:
J
From Complaint:
N
Standard:
Y
Survey Date:
2019-03-21
Corrected:
2019-05-21
Provide safe and appropriate respiratory care for a resident when needed.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-03-21
Corrected:
2019-05-21
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.
Category:
Nursing and Physician Services Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-03-21
Corrected:
2019-05-21
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Category:
Pharmacy Service Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-03-21
Corrected:
2019-07-30
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.
Category:
Pharmacy Service Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-03-21
Corrected:
2019-07-30
Ensure medication error rates are not 5 percent or greater.
Category:
Pharmacy Service Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-03-21
Corrected:
2019-05-21
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.
Category:
Pharmacy Service Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-03-21
Corrected:
2019-05-21
Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them.
Category:
Administration Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-03-21
Corrected:
2019-05-21
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-03-21
Corrected:
2019-05-21
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Category:
Administration Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-03-21
Corrected:
2019-05-21
Provide and implement an infection prevention and control program.
Category:
Infection Control Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-03-21
Corrected:
2019-05-21
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Category:
Resident Rights Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-03-21
Corrected:
2019-05-21
Ensure that residents are fully informed and understand their health status, care and treatments.
Category:
Resident Rights Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-03-21
Corrected:
2019-07-30
Reasonably accommodate the needs and preferences of each resident.
Category:
Resident Rights Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-03-21
Corrected:
2019-05-21
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Category:
Resident Rights Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-03-21
Corrected:
2019-05-21
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Category:
Resident Rights Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-03-21
Corrected:
2019-05-21
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.
Category:
Resident Rights Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-03-21
Corrected:
2019-05-21
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Category:
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-03-21
Corrected:
2019-05-21
Ensure that each resident is free from medications that restrain them, unless needed for medical treatment.
Category:
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-03-21
Corrected:
2019-05-21
Respond appropriately to all alleged violations.
Category:
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-03-21
Corrected:
2019-05-21
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Category:
Resident Rights Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-03-21
Corrected:
2019-05-21
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.
Category:
Resident Rights Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-03-21
Corrected:
2019-05-21
Ensure each resident receives an accurate assessment.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-03-21
Corrected:
2019-05-21
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-03-21
Corrected:
2019-07-30
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-03-21
Corrected:
2019-07-30
Provide activities to meet all resident's needs.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-03-21
Corrected:
2019-05-21
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-03-21
Corrected:
2019-07-30
Assist a resident in gaining access to vision and hearing services.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-03-21
Corrected:
2019-05-21
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-03-21
Corrected:
2019-05-21
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category:
Quality of Life and Care Deficiencies
Scope:
J
From Complaint:
N
Standard:
Y
Survey Date:
2019-03-21
Corrected:
2019-05-21
Provide safe and appropriate respiratory care for a resident when needed.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-03-21
Corrected:
2019-05-21
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.
Category:
Nursing and Physician Services Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-03-21
Corrected:
2019-05-21
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Category:
Pharmacy Service Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-03-21
Corrected:
2019-07-30
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.
Category:
Pharmacy Service Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-03-21
Corrected:
2019-07-30
Ensure medication error rates are not 5 percent or greater.
Category:
Pharmacy Service Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-03-21
Corrected:
2019-05-21
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.
Category:
Pharmacy Service Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-03-21
Corrected:
2019-05-21
Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them.
Category:
Administration Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-03-21
Corrected:
2019-05-21
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-03-21
Corrected:
2019-05-21
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Category:
Administration Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-03-21
Corrected:
2019-05-21
Provide and implement an infection prevention and control program.
Category:
Infection Control Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2019-03-21
Corrected:
2019-05-21
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Category:
Resident Rights Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2017-10-23
Corrected:
2018-01-19
Protect each resident from all abuse, physical punishment, and involuntary separation from others.
Category:
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Scope:
J
From Complaint:
N
Standard:
Y
Survey Date:
2017-10-23
Corrected:
2017-12-08
1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents.
Category:
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2017-10-23
Corrected:
2017-12-08
Provide housekeeping and maintenance services.
Category:
Environmental Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2017-10-23
Corrected:
2017-12-08
Ensure each resident receives an accurate assessment by a qualified health professional.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2017-10-23
Corrected:
2018-01-19
Allow residents the right to participate in the planning or revision of care and treatment.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2017-10-23
Corrected:
2018-01-19
Provide necessary care and services to maintain or improve the highest well being of each resident .
Category:
Quality of Life and Care Deficiencies
Scope:
G
From Complaint:
N
Standard:
Y
Survey Date:
2017-10-23
Corrected:
2018-01-19
Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2017-10-23
Corrected:
2017-12-08
Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents.
Category:
Environmental Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2017-10-23
Corrected:
2017-12-08
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.
Category:
Pharmacy Service Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2017-10-23
Corrected:
2017-12-08
Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%.
Category:
Pharmacy Service Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2017-10-23
Corrected:
2018-01-19
Have enough nurses to care for every resident in a way that maximizes the resident's well being.
Category:
Nursing and Physician Services Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2017-10-23
Corrected:
2018-01-19
Keep accurate, complete and organized clinical records on each resident that meet professional standards.
Category:
Administration Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2017-10-23
Corrected:
2018-01-19
Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action.
Category:
Administration Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2017-10-23
Corrected:
2018-01-19
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Category:
Resident Rights Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2017-10-23
Corrected:
2018-01-19
Protect each resident from all abuse, physical punishment, and involuntary separation from others.
Category:
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Scope:
J
From Complaint:
N
Standard:
Y
Survey Date:
2017-10-23
Corrected:
2017-12-08
1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents.
Category:
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2017-10-23
Corrected:
2017-12-08
Provide housekeeping and maintenance services.
Category:
Environmental Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2017-10-23
Corrected:
2017-12-08
Ensure each resident receives an accurate assessment by a qualified health professional.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2017-10-23
Corrected:
2018-01-19
Allow residents the right to participate in the planning or revision of care and treatment.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2017-10-23
Corrected:
2018-01-19
Provide necessary care and services to maintain or improve the highest well being of each resident .
Category:
Quality of Life and Care Deficiencies
Scope:
G
From Complaint:
N
Standard:
Y
Survey Date:
2017-10-23
Corrected:
2018-01-19
Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2017-10-23
Corrected:
2017-12-08
Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents.
Category:
Environmental Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2017-10-23
Corrected:
2017-12-08
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.
Category:
Pharmacy Service Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2017-10-23
Corrected:
2017-12-08
Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%.
Category:
Pharmacy Service Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2017-10-23
Corrected:
2018-01-19
Have enough nurses to care for every resident in a way that maximizes the resident's well being.
Category:
Nursing and Physician Services Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2017-10-23
Corrected:
2018-01-19
Keep accurate, complete and organized clinical records on each resident that meet professional standards.
Category:
Administration Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2017-10-23
Corrected:
2018-01-19
Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action.
Category:
Administration Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2017-10-23
Corrected:
2018-01-19
Give residents a notice of rights, rules, services and charges.
Category:
Resident Rights Deficiencies
Scope:
C
From Complaint:
N
Standard:
Y
Survey Date:
2016-08-19
Corrected:
2016-10-14
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Category:
Resident Rights Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2016-08-19
Corrected:
2016-10-14
1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents.
Category:
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2016-08-19
Corrected:
2016-10-14
Ensure residents have the right to have a choice over activities, their schedules, and health care according to their interests, assessments, and plans of care.
Category:
Resident Rights Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2016-08-19
Corrected:
2016-10-14
Provide housekeeping and maintenance services.
Category:
Environmental Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2016-08-19
Corrected:
2016-10-14
Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2016-08-19
Corrected:
2016-10-14
Allow residents the right to participate in the planning or revision of care and treatment.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2016-08-19
Corrected:
2016-10-14
Provide necessary care and services to maintain or improve the highest well being of each resident .
Category:
Quality of Life and Care Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2016-08-19
Corrected:
2016-10-14
Make sure that residents receive treatments/services to maintain or improve their ability to care for themselves.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2016-08-19
Corrected:
2016-10-14
Ensure that residents receive proper treatment and assistive devices to maintain their vision and hearing.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2016-08-19
Corrected:
2016-10-14
Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2016-08-19
Corrected:
2016-10-14
Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents.
Category:
Environmental Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2016-08-19
Corrected:
2016-10-14
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.
Category:
Pharmacy Service Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2016-08-19
Corrected:
2016-10-14
Develop policies and procedures for influenza and pneumococcal immunizations.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2016-08-19
Corrected:
2016-10-14
Post nurse staffing information/data on a daily basis.
Category:
Nursing and Physician Services Deficiencies
Scope:
C
From Complaint:
N
Standard:
Y
Survey Date:
2016-08-19
Corrected:
2016-10-14
Make sure that a doctor approves a resident's admission in writing and that each resident remains under the care of a doctor.
Category:
Nursing and Physician Services Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2016-08-19
Corrected:
2016-10-14
Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse.
Category:
Pharmacy Service Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2016-08-19
Corrected:
2016-10-14
Keep all essential equipment working safely.
Category:
Environmental Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2016-08-19
Corrected:
2016-10-14
Give or get quality laboratory services/tests in a timely manner to meet the needs of residents.
Category:
Administration Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2016-08-19
Corrected:
2016-10-14
Keep accurate, complete and organized clinical records on each resident that meet professional standards.
Category:
Administration Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2016-08-19
Corrected:
2016-10-14
Give residents a notice of rights, rules, services and charges.
Category:
Resident Rights Deficiencies
Scope:
C
From Complaint:
N
Standard:
Y
Survey Date:
2016-08-19
Corrected:
2016-10-14
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Category:
Resident Rights Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2016-08-19
Corrected:
2016-10-14
1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents.
Category:
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2016-08-19
Corrected:
2016-10-14
Ensure residents have the right to have a choice over activities, their schedules, and health care according to their interests, assessments, and plans of care.
Category:
Resident Rights Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2016-08-19
Corrected:
2016-10-14
Provide housekeeping and maintenance services.
Category:
Environmental Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2016-08-19
Corrected:
2016-10-14
Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2016-08-19
Corrected:
2016-10-14
Allow residents the right to participate in the planning or revision of care and treatment.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2016-08-19
Corrected:
2016-10-14
Provide necessary care and services to maintain or improve the highest well being of each resident .
Category:
Quality of Life and Care Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2016-08-19
Corrected:
2016-10-14
Make sure that residents receive treatments/services to maintain or improve their ability to care for themselves.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2016-08-19
Corrected:
2016-10-14
Ensure that residents receive proper treatment and assistive devices to maintain their vision and hearing.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2016-08-19
Corrected:
2016-10-14
Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2016-08-19
Corrected:
2016-10-14
Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents.
Category:
Environmental Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2016-08-19
Corrected:
2016-10-14
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.
Category:
Pharmacy Service Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2016-08-19
Corrected:
2016-10-14
Develop policies and procedures for influenza and pneumococcal immunizations.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2016-08-19
Corrected:
2016-10-14
Post nurse staffing information/data on a daily basis.
Category:
Nursing and Physician Services Deficiencies
Scope:
C
From Complaint:
N
Standard:
Y
Survey Date:
2016-08-19
Corrected:
2016-10-14
Make sure that a doctor approves a resident's admission in writing and that each resident remains under the care of a doctor.
Category:
Nursing and Physician Services Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2016-08-19
Corrected:
2016-10-14
Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse.
Category:
Pharmacy Service Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2016-08-19
Corrected:
2016-10-14
Keep all essential equipment working safely.
Category:
Environmental Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2016-08-19
Corrected:
2016-10-14
Give or get quality laboratory services/tests in a timely manner to meet the needs of residents.
Category:
Administration Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2016-08-19
Corrected:
2016-10-14
Keep accurate, complete and organized clinical records on each resident that meet professional standards.
Category:
Administration Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2016-08-19
Corrected:
2016-10-14

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