Chevy Chase, MD

Autumn Lake Healthcare At Chevy Chase

3-star overall rating with 3-star inspections with 27 recent health deficiencies with 17 fire-safety deficiencies in the latest cycle

8700 Jones Mill Road, Chevy Chase, MD

(301) 657-8686

Compare this facility

Overall

3 / 5

CMS overall stars

Health inspections

3 / 5

Survey and complaint cycles

Staffing

4 / 5

RN + nurse staffing

Quality measures

3 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

172

Certified beds

Average residents

147

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Autumn Lake Healthcare

Operator or chain grouping

Approved since

1967-01-01

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

0.74

Registered nurse staffing · state 0.81 · national 0.68

LPN hours / resident day

0.61

Licensed practical nurse staffing · state 0.91 · national 0.87

Aide hours / resident day

1.95

Nurse aide staffing · state 2.15 · national 2.35

Total nurse hours

3.30

All reported nurse hours · state 3.87 · national 3.89

Licensed hours

1.35

RN + LPN hours · state 1.72 · national 1.54

Weekend hours

3.01

Weekend nurse staffing · state 3.46 · national 3.43

Weekend RN hours

0.65

Weekend registered nurse coverage · state 0.61 · national 0.47

Physical therapist

0.08

Reported PT staffing · state 0.09 · national 0.07

Adjusted RN hours

0.76

CMS adjusted RN staffing hours

Adjusted total hours

3.35

CMS adjusted total nurse staffing hours

Case-mix index

1.35

Higher values indicate more complex resident acuity

RN turnover

27%

Annual RN turnover · state 40% · national 45%

Total nurse turnover

33%

Annual nurse turnover · state 41% · national 46%

SNF VBP

Value-based purchasing

Program rank

9,934

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

Performance score

21.99

Composite VBP score used to determine payment impact.

Payment multiplier

0.9828

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

0.56

Baseline 18.17% · Performance 21.17% · Measure score 0.56 · Achievement 0.56 · Improvement 0

Healthcare-associated infections

Baseline 6.11% · Performance 8.56% · Measure score 0 · Achievement 0 · Improvement 0

Total nurse turnover

7.42

Baseline 17.65% · Performance 33.33% · Measure score 7.42 · Achievement 7.42 · Improvement 0

Adjusted total nurse staffing

0.81

Baseline 3.14 hours · Performance 3.31 hours · Measure score 0.81 · Achievement 0.81 · Improvement 0.15

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	11.02%	10.72% 0.3 pts worse	No Different than the National Rate · Eligible stays 219 · Observed rate 9.59% · Lower 95% interval 8.02%
Discharge to community	43.83%	50.57% 6.7 pts worse	Worse than the National Rate · Eligible stays 237 · Observed rate 38.4% · Lower 95% interval 37.5%
Medicare spending per beneficiary	1.17	1.02 0.1 pts worse
Drug regimen review with follow-up	96.86%	95.27% 1.6 pts better	Numerator 154 · Denominator 159
Falls with major injury	1.26%	0.77% 0.5 pts worse	Numerator 2 · Denominator 159
Discharge self-care score	41.25%	53.69% 12.4 pts worse	Numerator 33 · Denominator 80
Discharge mobility score	42.5%	50.94% 8.4 pts worse	Numerator 34 · Denominator 80
Pressure ulcers or injuries, new or worsened	2.52%	2.29% 0.2 pts worse	Numerator 4 · Denominator 159 · Adjusted rate 1.78%
Healthcare-associated infections requiring hospitalization	8.56%	7.12% 1.4 pts worse	No Different than the National Rate · Eligible stays 127 · Observed rate 10.24% · Lower 95% interval 5.44%
Staff COVID-19 vaccination coverage	0%	8.2% 8.2 pts worse	Numerator 0 · Denominator 159
Staff flu vaccination coverage	84.76%	42% 42.8 pts better	Numerator 139 · Denominator 164
Discharge function score	45%	56.45% 11.5 pts worse	Numerator 36 · Denominator 80
Transfer of health information to provider	97.1%	95.95% 1.1 pts better	Numerator 67 · Denominator 69
Transfer of health information to patient	89.47%	96.28% 6.8 pts worse	Numerator 51 · Denominator 57
Resident COVID-19 vaccinations up to date	37.78%	25.2% 12.6 pts better	Numerator 34 · Denominator 90

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	2.3	1.3 1 pts worse	1.9 0.4 pts worse	Long Stay · 20240701-20250630 · Adjusted 2.3 · Observed 2.1 · Expected 1.7 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	1.6	1.2 0.4 pts worse	1.8 0.2 pts better	Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.4 · Expected 1.5 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	97.5%	91.9% 5.6 pts better	93.4% 4.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 96.1% · Q2 94.7% · Q3 99.2% · Q4 100.0% · 4Q avg 97.5%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	99.3%	96.6% 2.7 pts better	95.5% 3.8 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 99.3%
Percentage of long-stay residents experiencing one or more falls with major injury	2.3%	2.3% About the same	3.3% 1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 1.5% · Q3 1.6% · Q4 4.6% · 4Q avg 2.3% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	4.3%	21.4% 17.1 pts better	11.4% 7.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.7% · Q3 5.0% · Q4 11.4% · 4Q avg 4.3%
Percentage of long-stay residents who lose too much weight	8.1%	5.7% 2.4 pts worse	5.4% 2.7 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 9.9% · Q3 7.0% · Q4 11.2% · 4Q avg 8.1%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	7.4%	16.1% 8.7 pts better	19.6% 12.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 8.5% · Q2 6.6% · Q3 6.1% · Q4 8.5% · 4Q avg 7.4%
Percentage of long-stay residents who received an antipsychotic medication	14.4%	15.3% 0.9 pts better	16.7% 2.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 12.9% · Q2 15.5% · Q3 13.8% · Q4 15.3% · 4Q avg 14.4% · Used in QM five-star
Percentage of long-stay residents who were physically restrained	0.6%	0.0% 0.6 pts worse	0.1% 0.5 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.8% · Q3 0.8% · Q4 0.8% · 4Q avg 0.6%
Percentage of long-stay residents whose ability to walk independently worsened	35.2%	26.6% 8.6 pts worse	16.3% 18.9 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 37.8% · Q2 35.9% · Q3 26.6% · Q4 40.0% · 4Q avg 35.2% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	23.5%	22.9% 0.6 pts worse	14.9% 8.6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 24.8% · Q2 25.5% · Q3 23.0% · Q4 20.4% · 4Q avg 23.5% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.3%	0.7% 0.4 pts better	1.0% 0.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	0.4%	1.5% 1.1 pts better	1.7% 1.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.8% · Q4 0.8% · 4Q avg 0.4% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	21.6%	25.4% 3.8 pts better	19.8% 1.8 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 23.4% · Q2 22.7% · Q3 18.4% · Q4 22.2% · 4Q avg 21.6%
Percentage of long-stay residents with pressure ulcers	6.3%	6.3% About the same	5.1% 1.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 7.0% · Q2 6.0% · Q3 7.6% · Q4 4.7% · 4Q avg 6.3% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	77.2%	78.4% 1.2 pts worse	81.7% 4.5 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 66.2% · Q2 81.8% · Q3 79.1% · Q4 85.7% · 4Q avg 77.2%
Percentage of short-stay residents who had an outpatient emergency department visit	7.0%	9.9% 2.9 pts better	12.0% 5 pts better	Short Stay · 20240701-20250630 · Adjusted 7.0% · Observed 6.8% · Expected 10.7% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	0.0%	1.3% 1.3 pts better	1.6% 1.6 pts better	Short 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 short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	73.9%	80.6% 6.7 pts worse	79.7% 5.8 pts worse	Short Stay · 2024Q3-2025Q2 · 4Q avg 73.9%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	31.3%	21.2% 10.1 pts worse	23.9% 7.4 pts worse	Short Stay · 20240701-20250630 · Adjusted 31.3% · Observed 31.6% · Expected 24.0% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-04-28 · Fire 2025-04-28

27 health deficiencies

Top issue: Resident Rights (6 deficiencies)

17 fire-safety deficiencies

Top issue: Smoke (6 deficiencies)

Cycle 2 Health 2021-03-26 · Fire 2021-03-26

8 health deficiencies

Top issue: Pharmacy Service (4 deficiencies)

8 fire-safety deficiencies

Top issue: Smoke (3 deficiencies)

Cycle 3 Health 2019-06-21 · Fire 2019-06-21

7 health deficiencies

Top issue: Resident Assessment and Care Planning (2 deficiencies)

4 fire-safety deficiencies

Top issue: Smoke (2 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2025-04-28

E4 · Emergency Preparedness Deficiencies

Fire Safety

Develop and maintain an Emergency Preparedness Program (EP).

Corrected 2025-07-31

F · Potential for more than minimal harm 2025-04-28

K345 · Smoke Deficiencies

Fire Safety

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

Corrected 2025-07-31

F · Potential for more than minimal harm 2025-04-28

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2025-07-31

F · Potential for more than minimal harm 2025-04-28

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2025-07-31

F · Potential for more than minimal harm 2025-04-28

K761 · Miscellaneous Deficiencies

Fire Safety

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

Corrected 2025-07-31

F · Potential for more than minimal harm 2025-04-28

K914 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

Corrected 2025-07-31

F · Potential for more than minimal harm 2025-04-28

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

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

Corrected 2025-07-31

E · Potential for more than minimal harm 2025-04-28

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 2025-07-31

E · Potential for more than minimal harm 2025-04-28

K293 · Egress Deficiencies

Fire Safety

Have properly located and lighted "Exit" signs.

Corrected 2025-07-31

E · Potential for more than minimal harm 2025-04-28

K341 · Smoke Deficiencies

Fire Safety

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

Corrected 2025-07-31

E · Potential for more than minimal harm 2025-04-28

K362 · Smoke Deficiencies

Fire Safety

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

Corrected 2025-07-31

E · Potential for more than minimal harm 2025-04-28

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2025-07-31

D · Potential for more than minimal harm 2025-04-28

K100 · Construction Deficiencies

Fire Safety

Meet other general requirements.

Corrected 2025-07-31

D · Potential for more than minimal harm 2025-04-28

K211 · Egress Deficiencies

Fire Safety

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

Corrected 2025-07-31

D · Potential for more than minimal harm 2025-04-28

K352 · Smoke Deficiencies

Fire Safety

Properly install and monitor supervisory attachments on automatic sprinkler systems.

Corrected 2025-07-31

D · Potential for more than minimal harm 2025-04-28

K355 · Smoke Deficiencies

Fire Safety

Properly select, install, inspect, or maintain portable fire extinguishes.

Corrected 2025-07-31

D · Potential for more than minimal harm 2025-04-28

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2025-07-31

F · Potential for more than minimal harm 2021-03-26

K345 · Smoke Deficiencies

Fire Safety

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

Corrected 2021-04-29

F · Potential for more than minimal harm 2021-03-26

K761 · Miscellaneous Deficiencies

Fire Safety

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

Corrected 2021-04-29

F · Potential for more than minimal harm 2021-03-26

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

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

Corrected 2021-04-29

E · Potential for more than minimal harm 2021-03-26

K351 · Smoke Deficiencies

Fire Safety

Install an approved automatic sprinkler system.

Corrected 2021-04-29

D · Potential for more than minimal harm 2021-03-26

K211 · Egress Deficiencies

Fire Safety

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

Corrected 2021-04-29

D · Potential for more than minimal harm 2021-03-26

K355 · Smoke Deficiencies

Fire Safety

Properly select, install, inspect, or maintain portable fire extinguishes.

Corrected 2021-04-29

D · Potential for more than minimal harm 2021-03-26

K500 · Services Deficiencies

Fire Safety

Meet other general requirements that are deficient.

Corrected 2021-04-29

D · Potential for more than minimal harm 2021-03-26

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2021-04-29

D · Potential for more than minimal harm 2019-06-21

K781 · Miscellaneous Deficiencies

Fire Safety

Have restrictions on the use of portable space heaters.

Corrected 2019-06-28

C · Minimal harm 2019-06-21

K321 · Smoke Deficiencies

Fire Safety

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Corrected 2019-06-28

B · Minimal harm 2019-06-21

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2019-06-28

B · Minimal harm 2019-06-21

K911 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Meet requirements for the installation and maintenance of electrical systems.

Corrected 2019-06-28

Inspection history

Recent health citations

D · Potential for more than minimal harm 2025-10-17

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 2025-12-05

D · Potential for more than minimal harm 2025-10-17

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-12-05

E · Potential for more than minimal harm 2025-04-28

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 2025-06-11

E · Potential for more than minimal harm 2025-04-28

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 2025-06-11

E · Potential for more than minimal harm 2025-04-28

F658 · Resident Assessment and Care Planning Deficiencies

Health

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

Corrected 2025-06-11

D · Potential for more than minimal harm 2025-04-28

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 2025-06-11

D · Potential for more than minimal harm 2025-04-28

F558 · Resident Rights Deficiencies

Health

Reasonably accommodate the needs and preferences of each resident.

Corrected 2025-06-11

D · Potential for more than minimal harm 2025-04-28

F573 · Resident Rights Deficiencies

Health

Let each resident or the resident's legal representative access or purchase copies of all the resident's records.

Corrected 2025-06-11

D · Potential for more than minimal harm 2025-04-28

F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Respond appropriately to all alleged violations.

Corrected 2025-06-11

D · Potential for more than minimal harm 2025-04-28

F622 · Resident Rights Deficiencies

Health

Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.

Corrected 2025-06-11

D · Potential for more than minimal harm 2025-04-28

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 2025-06-11

D · Potential for more than minimal harm 2025-04-28

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2025-06-11

D · Potential for more than minimal harm 2025-04-28

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 2025-06-11

D · Potential for more than minimal harm 2025-04-28

F677 · Quality of Life and Care Deficiencies

Health

Provide care and assistance to perform activities of daily living for any resident who is unable.

Corrected 2025-06-11

D · Potential for more than minimal harm 2025-04-28

F688 · Quality of Life and Care Deficiencies

Health

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Corrected 2025-06-11

D · Potential for more than minimal harm 2025-04-28

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 2025-06-11

D · Potential for more than minimal harm 2025-04-28

F757 · Pharmacy Service Deficiencies

Health

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

Corrected 2025-06-11

D · Potential for more than minimal harm 2025-04-28

F800 · Nutrition and Dietary Deficiencies

Health

Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.

Corrected 2025-06-11

D · Potential for more than minimal harm 2025-04-28

F804 · Nutrition and Dietary Deficiencies

Health

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Corrected 2025-06-11

D · Potential for more than minimal harm 2025-04-28

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2025-06-11

D · Potential for more than minimal harm 2025-04-28

F838 · Administration Deficiencies

Health

Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.

Corrected 2025-06-11

D · Potential for more than minimal harm 2025-04-28

F840 · Administration Deficiencies

Health

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.

Corrected 2025-06-11

D · Potential for more than minimal harm 2025-04-28

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 2025-06-11

D · Potential for more than minimal harm 2025-04-28

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-06-11

D · Potential for more than minimal harm 2025-04-28

F908 · Environmental Deficiencies

Health

Keep all essential equipment working safely.

Corrected 2025-06-11

D · Potential for more than minimal harm 2025-04-28

F909 · Environmental Deficiencies

Health

Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.

Corrected 2025-06-11

B · Minimal harm 2025-04-28

F732 · Nursing and Physician Services Deficiencies

Health

Post nurse staffing information every day.

Corrected 2025-06-11

D · Potential for more than minimal harm 2021-03-26

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 2021-05-06

D · Potential for more than minimal harm 2021-03-26

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 2021-05-06

D · Potential for more than minimal harm 2021-03-26

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 2021-05-06

D · Potential for more than minimal harm 2021-03-26

F757 · Pharmacy Service Deficiencies

Health

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

Corrected 2021-05-06

D · Potential for more than minimal harm 2021-03-26

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 2021-05-06

D · Potential for more than minimal harm 2021-03-26

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 2021-05-06

D · Potential for more than minimal harm 2021-03-26

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2021-05-06

B · Minimal harm 2021-03-26

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2021-05-06

E · Potential for more than minimal harm 2019-06-21

F684 · Quality of Life and Care Deficiencies

Health

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

Corrected 2019-08-01

E · Potential for more than minimal harm 2019-06-21

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2019-08-01

D · Potential for more than minimal harm 2019-06-21

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 2019-08-01

D · Potential for more than minimal harm 2019-06-21

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 2019-08-01

D · Potential for more than minimal harm 2019-06-21

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 2019-08-01

D · Potential for more than minimal harm 2019-06-21

F840 · Administration Deficiencies

Health

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.

Corrected 2019-08-01

B · Minimal harm 2019-06-21

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 2019-08-01

Penalties and ownership