Glen Burnie, MD

Autumn Lake Healthcare At Baltimore Washington

2-star overall rating with 2-star inspections with 34 recent health deficiencies with 14 fire-safety deficiencies in the latest cycle

313 Hospital Drive, Glen Burnie, MD

(410) 761-1222

Compare this facility

Overall

2 / 5

CMS overall stars

Health inspections

2 / 5

Survey and complaint cycles

Staffing

2 / 5

RN + nurse staffing

Quality measures

3 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

129

Certified beds

Average residents

101

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Autumn Lake Healthcare

Operator or chain grouping

Approved since

1997-09-04

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

60 facilities

Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars

Changed ownership

Within the last 12 months

Family council

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

0.68

Registered nurse staffing · state 0.81 · national 0.68

LPN hours / resident day

0.72

Licensed practical nurse staffing · state 0.91 · national 0.87

Aide hours / resident day

1.89

Nurse aide staffing · state 2.15 · national 2.35

Total nurse hours

3.28

All reported nurse hours · state 3.87 · national 3.89

Licensed hours

1.40

RN + LPN hours · state 1.72 · national 1.54

Weekend hours

3.04

Weekend nurse staffing · state 3.46 · national 3.43

Weekend RN hours

0.63

Weekend registered nurse coverage · state 0.61 · national 0.47

Physical therapist

0.06

Reported PT staffing · state 0.09 · national 0.07

Adjusted RN hours

0.59

CMS adjusted RN staffing hours

Adjusted total hours

2.89

CMS adjusted total nurse staffing hours

Case-mix index

1.55

Higher values indicate more complex resident acuity

RN turnover

31%

Annual RN turnover · state 40% · national 45%

Total nurse turnover

51%

Annual nurse turnover · state 41% · national 46%

SNF VBP

Value-based purchasing

Program rank

12,832

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

10.20

Composite VBP score used to determine payment impact.

Payment multiplier

0.9809

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

Baseline 16.35% · Performance 21.40% · Measure score 0 · Achievement 0 · Improvement 0

Healthcare-associated infections

Baseline 7.78% · Performance 8.37% · Measure score 0 · Achievement 0 · Improvement 0

Total nurse turnover

3.49

Performance 49.43% · Measure score 3.49 · Achievement 3.49 · This facility did not have sufficient data to calculate a baseline period measure result.

Adjusted total nurse staffing

0.59

Baseline 3.32 hours · Performance 3.25 hours · Measure score 0.59 · Achievement 0.59 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	14.94%	10.72% 4.2 pts worse	Worse than the National Rate · Eligible stays 332 · Observed rate 18.37% · Lower 95% interval 12.14%
Discharge to community	58.08%	50.57% 7.5 pts better	Better than the National Rate · Eligible stays 296 · Observed rate 52.03% · Lower 95% interval 50.91%
Medicare spending per beneficiary	1.12	1.02 0.1 pts worse
Drug regimen review with follow-up	74.29%	95.27% 21 pts worse	Numerator 156 · Denominator 210
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 209
Discharge self-care score	33.08%	53.69% 20.6 pts worse	Numerator 44 · Denominator 133
Discharge mobility score	33.83%	50.94% 17.1 pts worse	Numerator 45 · Denominator 133
Pressure ulcers or injuries, new or worsened	11.48%	2.29% 9.2 pts worse	Numerator 24 · Denominator 209 · Adjusted rate 9.04%
Healthcare-associated infections requiring hospitalization	8.37%	7.12% 1.2 pts worse	No Different than the National Rate · Eligible stays 189 · Observed rate 10.05% · Lower 95% interval 5.59%
Staff COVID-19 vaccination coverage	13.33%	8.2% 5.1 pts better	Numerator 8 · Denominator 60
Staff flu vaccination coverage	95.38%	42% 53.4 pts better	Numerator 124 · Denominator 130
Discharge function score	44.36%	56.45% 12.1 pts worse	Numerator 59 · Denominator 133
Transfer of health information to provider	100%	95.95% 4 pts better	Numerator 65 · Denominator 65
Transfer of health information to patient	93.94%	96.28% 2.3 pts worse	Numerator 93 · Denominator 99
Resident COVID-19 vaccinations up to date	8.04%	25.2% 17.2 pts worse	Numerator 9 · Denominator 112

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	1.8	1.3 0.5 pts worse	1.9 0.1 pts better	Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 2.0 · Expected 2.1 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	0.9	1.2 0.3 pts better	1.8 0.9 pts better	Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 0.9 · Expected 1.6 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	94.6%	91.9% 2.7 pts better	93.4% 1.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 93.8% · Q2 93.1% · Q3 95.9% · Q4 95.8% · 4Q avg 94.6%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	90.5%	96.6% 6.1 pts worse	95.5% 5 pts worse	Long Stay · 2024Q3-2025Q2 · 4Q avg 90.5%
Percentage of long-stay residents experiencing one or more falls with major injury	1.3%	2.3% 1 pts better	3.3% 2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 1.4% · Q3 1.4% · Q4 0.0% · 4Q avg 1.3% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	66.8%	21.4% 45.4 pts worse	11.4% 55.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 75.0% · Q3 100.0% · Q4 95.4% · 4Q avg 66.8%
Percentage of long-stay residents who lose too much weight	5.0%	5.7% 0.7 pts better	5.4% 0.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 10.5% · Q2 3.1% · Q3 4.3% · Q4 1.4% · 4Q avg 5.0%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	9.2%	16.1% 6.9 pts better	19.6% 10.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 11.7% · Q2 7.4% · Q3 10.1% · Q4 7.2% · 4Q avg 9.2%
Percentage of long-stay residents who received an antipsychotic medication	7.3%	15.3% 8 pts better	16.7% 9.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 7.9% · Q2 6.8% · Q3 5.2% · Q4 9.3% · 4Q avg 7.3% · Used in QM five-star
Percentage of long-stay residents who were physically restrained	0.0%	0.0% About the same	0.1% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents whose need for help with daily activities has increased	32.5%	22.9% 9.6 pts worse	14.9% 17.6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 36.5% · Q2 25.8% · Q3 39.4% · Q4 27.7% · 4Q avg 32.5% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.9%	0.7% 0.2 pts worse	1.0% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 0.0% · Q3 1.3% · Q4 1.2% · 4Q avg 0.9% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	0.0%	1.5% 1.5 pts better	1.7% 1.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	24.5%	25.4% 0.9 pts better	19.8% 4.7 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 24.8% · Q2 22.9% · Q3 32.4% · Q4 18.0% · 4Q avg 24.5%
Percentage of long-stay residents with pressure ulcers	9.7%	6.3% 3.4 pts worse	5.1% 4.6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 12.5% · Q2 8.2% · Q3 9.2% · Q4 8.6% · 4Q avg 9.7% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	60.8%	78.4% 17.6 pts worse	81.7% 20.9 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 52.0% · Q2 54.6% · Q3 62.8% · Q4 75.1% · 4Q avg 60.8%
Percentage of short-stay residents who had an outpatient emergency department visit	8.3%	9.9% 1.6 pts better	12.0% 3.7 pts better	Short Stay · 20240701-20250630 · Adjusted 8.3% · Observed 8.2% · Expected 10.9% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	0.9%	1.3% 0.4 pts better	1.6% 0.7 pts better	Short Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 0.6% · Q3 0.7% · Q4 0.8% · 4Q avg 0.9% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	60.9%	80.6% 19.7 pts worse	79.7% 18.8 pts worse	Short Stay · 2024Q3-2025Q2 · 4Q avg 60.9%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	28.0%	21.2% 6.8 pts worse	23.9% 4.1 pts worse	Short Stay · 20240701-20250630 · Adjusted 28.0% · Observed 31.0% · Expected 26.4% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2024-09-09 · Fire 2024-09-09

34 health deficiencies

Top issue: Quality of Life and Care (9 deficiencies)

14 fire-safety deficiencies

Top issue: Smoke (5 deficiencies)

Cycle 2 Health 2019-10-15 · Fire 2019-10-15

19 health deficiencies

Top issue: Quality of Life and Care (6 deficiencies)

5 fire-safety deficiencies

Top issue: Egress (2 deficiencies)

Cycle 3 Health 2018-05-01 · Fire 2018-05-01

19 health deficiencies

Top issue: Resident Rights (5 deficiencies)

3 fire-safety deficiencies

Top issue: Egress (1 deficiency)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2024-09-09

E4 · Emergency Preparedness Deficiencies

Fire Safety

Develop and maintain an Emergency Preparedness Program (EP).

Corrected 2024-10-17

F · Potential for more than minimal harm 2024-09-09

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2024-10-17

E · Potential for more than minimal harm 2024-09-09

K211 · Egress Deficiencies

Fire Safety

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Corrected 2024-10-17

E · Potential for more than minimal harm 2024-09-09

K223 · Egress Deficiencies

Fire Safety

Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.

Corrected 2024-10-17

E · Potential for more than minimal harm 2024-09-09

K293 · Egress Deficiencies

Fire Safety

Have properly located and lighted "Exit" signs.

Corrected 2024-10-17

E · Potential for more than minimal harm 2024-09-09

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2024-10-17

E · Potential for more than minimal harm 2024-09-09

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2024-10-17

E · Potential for more than minimal harm 2024-09-09

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2024-10-17

E · Potential for more than minimal harm 2024-09-09

K521 · Services Deficiencies

Fire Safety

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Corrected 2024-10-17

D · Potential for more than minimal harm 2024-09-09

K225 · Egress Deficiencies

Fire Safety

Have stairways and smokeproof enclosures used as exits that meet safety requirements.

Corrected 2024-10-17

D · Potential for more than minimal harm 2024-09-09

K341 · Smoke Deficiencies

Fire Safety

Install a fire alarm system that can be heard throughout the facility.

Corrected 2024-10-17

D · Potential for more than minimal harm 2024-09-09

K351 · Smoke Deficiencies

Fire Safety

Install an approved automatic sprinkler system.

Corrected 2024-10-17

D · Potential for more than minimal harm 2024-09-09

K362 · Smoke Deficiencies

Fire Safety

Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.

Corrected 2024-10-17

D · Potential for more than minimal harm 2024-09-09

K741 · Miscellaneous Deficiencies

Fire Safety

Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

Corrected 2024-10-17

D · Potential for more than minimal harm 2019-10-15

K223 · Egress Deficiencies

Fire Safety

Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.

Corrected 2019-11-22

D · Potential for more than minimal harm 2019-10-15

K241 · Egress Deficiencies

Fire Safety

Have correct number of accessible exits for each story.

Corrected 2019-11-22

D · Potential for more than minimal harm 2019-10-15

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2019-11-22

D · Potential for more than minimal harm 2019-10-15

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2019-11-22

D · Potential for more than minimal harm 2019-10-15

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2019-11-22

D · Potential for more than minimal harm 2018-05-01

K271 · Egress Deficiencies

Fire Safety

Have exits that are accessible at all times.

Corrected 2018-05-31

D · Potential for more than minimal harm 2018-05-01

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2018-05-31

D · Potential for more than minimal harm 2018-05-01

K741 · Miscellaneous Deficiencies

Fire Safety

Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

Corrected 2018-05-31

Inspection history

Recent health citations

D · Potential for more than minimal harm 2025-10-30

F693 · Quality of Life and Care Deficiencies

Health

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.

Corrected 2025-11-26

D · Potential for more than minimal harm 2025-05-02

F580 · Resident Rights Deficiencies

Health

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Corrected 2025-06-16

D · Potential for more than minimal harm 2025-05-02

F584 · Resident Rights Deficiencies

Health

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.

Corrected 2025-06-16

D · Potential for more than minimal harm 2025-05-02

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected 2025-06-16

D · Potential for more than minimal harm 2025-05-02

F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Respond appropriately to all alleged violations.

Corrected 2025-06-16

D · Potential for more than minimal harm 2025-05-02

F656 · Resident Assessment and Care Planning Deficiencies

Health

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected 2025-06-16

D · Potential for more than minimal harm 2025-05-02

F692 · Quality of Life and Care Deficiencies

Health

Provide enough food/fluids to maintain a resident's health.

Corrected 2025-06-16

D · Potential for more than minimal harm 2025-05-02

F842 · Resident Assessment and Care Planning Deficiencies

Health

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Corrected 2025-06-16

D · Potential for more than minimal harm 2025-05-02

F917 · Environmental Deficiencies

Health

Make sure each resident has 1) at least one window to the outside in a room; 2) a room at or above ground level; 3) adequate bedding; 4) furniture that meets the resident's needs; or 5) adequate closet space.

Corrected 2025-06-16

F · Potential for more than minimal harm 2024-09-09

F801 · Nutrition and Dietary Deficiencies

Health

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.

Corrected 2024-10-23

F · Potential for more than minimal harm 2024-09-09

F925 · Environmental Deficiencies

Health

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Corrected 2024-10-23

E · Potential for more than minimal harm 2024-09-09

F584 · Resident Rights Deficiencies

Health

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.

Corrected 2024-10-23

E · Potential for more than minimal harm 2024-09-09

F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Respond appropriately to all alleged violations.

Corrected 2024-10-23

E · Potential for more than minimal harm 2024-09-09

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2024-10-23

D · Potential for more than minimal harm 2024-09-09

F550 · Resident Rights Deficiencies

Health

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Corrected 2024-10-23

D · Potential for more than minimal harm 2024-09-09

F583 · Resident Rights Deficiencies

Health

Keep residents' personal and medical records private and confidential.

Corrected 2024-10-23

D · Potential for more than minimal harm 2024-09-09

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected 2024-10-23

D · Potential for more than minimal harm 2024-09-09

F623 · Resident Rights Deficiencies

Health

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Corrected 2024-10-23

D · Potential for more than minimal harm 2024-09-09

F655 · Resident Assessment and Care Planning Deficiencies

Health

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Corrected 2024-10-23

D · Potential for more than minimal harm 2024-09-09

F656 · Resident Assessment and Care Planning Deficiencies

Health

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected 2024-10-23

D · Potential for more than minimal harm 2024-09-09

F657 · Resident Assessment and Care Planning Deficiencies

Health

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Corrected 2024-10-23

D · Potential for more than minimal harm 2024-09-09

F658 · Resident Assessment and Care Planning Deficiencies

Health

Ensure services provided by the nursing facility meet professional standards of quality.

Corrected 2024-10-23

D · Potential for more than minimal harm 2024-09-09

F676 · Quality of Life and Care Deficiencies

Health

Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

Corrected 2024-10-23

D · Potential for more than minimal harm 2024-09-09

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2024-10-23

D · Potential for more than minimal harm 2024-09-09

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2024-10-23

D · Potential for more than minimal harm 2024-09-09

F690 · Quality of Life and Care Deficiencies

Health

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Corrected 2024-10-23

D · Potential for more than minimal harm 2024-09-09

F692 · Quality of Life and Care Deficiencies

Health

Provide enough food/fluids to maintain a resident's health.

Corrected 2024-10-23

D · Potential for more than minimal harm 2024-09-09

F693 · Quality of Life and Care Deficiencies

Health

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.

Corrected 2024-10-23

D · Potential for more than minimal harm 2024-09-09

F697 · Quality of Life and Care Deficiencies

Health

Provide safe, appropriate pain management for a resident who requires such services.

Corrected 2024-10-23

D · Potential for more than minimal harm 2024-09-09

F726 · Nursing and Physician Services Deficiencies

Health

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.

Corrected 2024-10-23

D · Potential for more than minimal harm 2024-09-09

F730 · Nursing and Physician Services Deficiencies

Health

Observe each nurse aide's job performance and give regular training.

Corrected 2024-10-23

D · Potential for more than minimal harm 2024-09-09

F755 · Pharmacy Service Deficiencies

Health

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Corrected 2024-10-23

D · Potential for more than minimal harm 2024-09-09

F756 · Pharmacy Service Deficiencies

Health

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Corrected 2024-10-23

D · Potential for more than minimal harm 2024-09-09

F757 · Pharmacy Service Deficiencies

Health

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Corrected 2024-10-23

D · Potential for more than minimal harm 2024-09-09

F758 · Pharmacy Service Deficiencies

Health

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.

Corrected 2024-10-23

D · Potential for more than minimal harm 2024-09-09

F761 · Pharmacy Service Deficiencies

Health

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.

Corrected 2024-10-23

D · Potential for more than minimal harm 2024-09-09

F842 · Resident Assessment and Care Planning Deficiencies

Health

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Corrected 2024-10-23

D · Potential for more than minimal harm 2024-09-09

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-10-23

D · Potential for more than minimal harm 2024-09-09

F924 · Environmental Deficiencies

Health

Put firmly secured handrails on each side of hallways.

Corrected 2024-10-23

E · Potential for more than minimal harm 2019-10-15

F661 · Resident Assessment and Care Planning Deficiencies

Health

Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.

Corrected 2019-11-25

E · Potential for more than minimal harm 2019-10-15

F923 · Environmental Deficiencies

Health

Have enough outside ventilation via a window or mechanical ventilation, or both.

Corrected 2019-11-25

D · Potential for more than minimal harm 2019-10-15

F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Respond appropriately to all alleged violations.

Corrected 2019-11-25

D · Potential for more than minimal harm 2019-10-15

F623 · Resident Rights Deficiencies

Health

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Corrected 2019-11-25

D · Potential for more than minimal harm 2019-10-15

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2019-11-25

D · Potential for more than minimal harm 2019-10-15

F656 · Resident Assessment and Care Planning Deficiencies

Health

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected 2019-11-25

D · Potential for more than minimal harm 2019-10-15

F679 · Quality of Life and Care Deficiencies

Health

Provide activities to meet all resident's needs.

Corrected 2019-11-25

D · Potential for more than minimal harm 2019-10-15

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2019-11-25

D · Potential for more than minimal harm 2019-10-15

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2019-11-25

D · Potential for more than minimal harm 2019-10-15

F697 · Quality of Life and Care Deficiencies

Health

Provide safe, appropriate pain management for a resident who requires such services.

Corrected 2019-11-25

D · Potential for more than minimal harm 2019-10-15

F759 · Pharmacy Service Deficiencies

Health

Ensure medication error rates are not 5 percent or greater.

Corrected 2019-11-25

D · Potential for more than minimal harm 2019-10-15

F791 · Quality of Life and Care Deficiencies

Health

Provide or obtain dental services for each resident.

Corrected 2019-11-25

D · Potential for more than minimal harm 2019-10-15

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2019-11-25

D · Potential for more than minimal harm 2019-10-15

F925 · Environmental Deficiencies

Health

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Corrected 2019-11-25

E · Potential for more than minimal harm 2018-05-01

F550 · Resident Rights Deficiencies

Health

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Corrected 2018-06-15

E · Potential for more than minimal harm 2018-05-01

F585 · Resident Rights Deficiencies

Health

Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

Corrected 2018-06-15

E · Potential for more than minimal harm 2018-05-01

F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected 2018-06-15

E · Potential for more than minimal harm 2018-05-01

F725 · Nursing and Physician Services Deficiencies

Health

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Corrected 2018-06-15

E · Potential for more than minimal harm 2018-05-01

F842 · Resident Assessment and Care Planning Deficiencies

Health

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Corrected 2018-06-15

E · Potential for more than minimal harm 2018-05-01

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2018-06-15

D · Potential for more than minimal harm 2018-05-01

F561 · Resident Rights Deficiencies

Health

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

Corrected 2018-06-15

D · Potential for more than minimal harm 2018-05-01

F584 · Resident Rights Deficiencies

Health

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.

Corrected 2018-06-15

D · Potential for more than minimal harm 2018-05-01

F656 · Resident Assessment and Care Planning Deficiencies

Health

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected 2018-06-15

D · Potential for more than minimal harm 2018-05-01

F657 · Resident Assessment and Care Planning Deficiencies

Health

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Corrected 2018-06-15

D · Potential for more than minimal harm 2018-05-01

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2018-06-15

D · Potential for more than minimal harm 2018-05-01

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2018-06-15

D · Potential for more than minimal harm 2018-05-01

F692 · Quality of Life and Care Deficiencies

Health

Provide enough food/fluids to maintain a resident's health.

Corrected 2018-06-15

D · Potential for more than minimal harm 2018-05-01

F697 · Quality of Life and Care Deficiencies

Health

Provide safe, appropriate pain management for a resident who requires such services.

Corrected 2018-06-15

D · Potential for more than minimal harm 2018-05-01

F712 · Nursing and Physician Services Deficiencies

Health

Ensure that the resident and his/her doctor meet face-to-face at all required visits.

Corrected 2018-06-15

D · Potential for more than minimal harm 2018-05-01

F756 · Pharmacy Service Deficiencies

Health

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Corrected 2018-06-15

D · Potential for more than minimal harm 2018-05-01

F773 · Administration Deficiencies

Health

Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.

Corrected 2018-06-15

D · Potential for more than minimal harm 2018-05-01

F809 · Nutrition and Dietary Deficiencies

Health

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.

Corrected 2018-06-15

B · Minimal harm 2018-05-01