AUTUMN LAKE HEALTHCARE AT SUMMIT PARK Nursing Home


AUTUMN LAKE HEALTHCARE AT SUMMIT PARK (CCN: 215326) is a For profit - Corporation facility located in CATONSVILLE, MD (21228). The facility has an overall rating of 1/5, health inspection rating of 1/5, and a staffing rating of 1/5. It offers 143 certified beds and maintains an average of 112. residents per day. The nursing staff includes Nurse Aides, LPNs, and RNs working 3.17893 total hours per resident per day. It has been certified since December 21, 1999 and the last listed health inspection was on March 21, 2019, The facility is located in Baltimore county and provides senior and nursing home care.

AUTUMN LAKE HEALTHCARE AT SUMMIT PARK Summary


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Provider Name: AUTUMN LAKE HEALTHCARE AT SUMMIT PARK

Address: 1502 FREDERICK ROAD, CATONSVILLE, MD 21228

Phone: (410) 747-3287

County: Baltimore (020)

Ownership Type: For profit - Corporation

Certified Beds: 143

Average Residents Per Day: 112. ()

Provider Type: Medicare and Medicaid, Resides in Hospital: No

Legal Business Name: 1502 FREDERICK ROAD OPCO LLC

First Approved Date: December 21, 1999

Affiliated Entity: AUTUMN LAKE HEALTHCARE (56)

Retirement Community: N, Special Focus Status:

Ownership Change in Last 12 Months: N

Resident Family Council: Both

Sprinkler System Status: Yes

Overall Rating: 1 ()

Health Inspection Rating: 1 ()

QM Rating: 3 ()

Long Stay QM Rating: 1 ()

Short Stay QM Rating: 5 ()

Staffing Rating: 1 ()

Staffing Report Note:

PT Staffing Note:

Nurse Aide Staff Hours Per Day, per resident: 1.76668, LPN Staff Hours Per Day: 0.6589, RN Staff Hours Per Day: 0.7533, Licensed Staff Hours Per Day: 1.4122

Total Nurse Staff Hours Per Day, per resident: 3.17893

Weekend Nurse Staff Hours: 2.63023, Weekend RN Staff Hours: 0.5437

PT Staff Hours Per Day, per resident: 0.1146

Nurse Staff Turnover: 56.0, Nurse Turnover Note:

RN Turnover: 70.4, RN Turnover Note:

Admin Left Number: 3, Admin Turnover Note:

Case Mix Nurse Aide Hours Per Day, per resident: 2.1164, Case Mix LPN Hours Per Day: 0.8124, Case Mix RN Hours Per Day: 0.4508

Adjusted Nurse Aide Hours Per Day, per resident: 1.70059, Adjusted LPN Hours Per Day: 0.5985, Adjusted RN Hours Per Day: 0.6295

Total Adjusted Nurse Hours Per Day, per resident: 2.96476

Adjusted Weekend Nurse Hours Per Day, per resident: 2.45303

Health Survey Dates and Scores: Cycle 1: 2019-03-21 (Score: 195), Cycle 2: 2017-10-23 (Score: 151), Cycle 3: 2016-08-19 (Score: 140)

Total Weighted Health Score: 245.50

Reported Incidents: 2, Substantiated Complaints: 3

Infection Control Citations: 0

Fines and Penalties: Number of Fines: 1, Total Fines in Dollars: 9750.00, Payment Denials Number: 0, Total Penalties Number: 1

Location and GPS: 1502 FREDERICK ROAD,CATONSVILLE,MD,21228 (39.2685, -76.748)

Process Date: 2024-03-01


Health Inspection Citations Details

Each record details specific health deficiencies found during inspections, categorized by type, severity, and whether they were corrected. Below are the severity levels and their implications:

Citation on 2023-11-13

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

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-12-20

Citation on 2023-11-13

Type: Health, Deficiency: Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-12-20

Citation on 2019-03-21

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

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2019-05-21

Citation on 2019-03-21

Type: Health, Deficiency: Ensure that residents are fully informed and understand their health status, care and treatments.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2019-07-30

Citation on 2019-03-21

Type: Health, Deficiency: Reasonably accommodate the needs and preferences of each resident.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2019-05-21

Citation on 2019-03-21

Type: Health, Deficiency: Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2019-05-21

Citation on 2019-03-21

Type: Health, Deficiency: Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2019-05-21

Citation on 2019-03-21

Type: Health, Deficiency: 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.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2019-05-21

Citation on 2019-03-21

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

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2019-05-21

Citation on 2019-03-21

Type: Health, Deficiency: Ensure that each resident is free from medications that restrain them, unless needed for medical treatment.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2019-05-21

Citation on 2019-03-21

Type: Health, Deficiency: Respond appropriately to all alleged violations.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2019-05-21

Citation on 2019-03-21

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

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2019-05-21

Citation on 2019-03-21

Type: Health, Deficiency: 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.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2019-05-21

Citation on 2019-03-21

Type: Health, Deficiency: Ensure each resident receives an accurate assessment.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2019-05-21

Citation on 2019-03-21

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

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2019-07-30

Citation on 2019-03-21

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

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2019-07-30

Citation on 2019-03-21

Type: Health, Deficiency: Provide activities to meet all resident's needs.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2019-05-21

Citation on 2019-03-21

Type: Health, Deficiency: Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2019-07-30

Citation on 2019-03-21

Type: Health, Deficiency: Assist a resident in gaining access to vision and hearing services.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2019-05-21

Citation on 2019-03-21

Type: Health, Deficiency: Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2019-05-21

Citation on 2019-03-21

Type: Health, Deficiency: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Severity: J - Level 4: Immediate jeopardy to resident health or safety. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2019-05-21

Citation on 2019-03-21

Type: Health, Deficiency: Provide safe and appropriate respiratory care for a resident when needed.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2019-05-21

Citation on 2019-03-21

Type: Health, Deficiency: 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.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2019-05-21

Citation on 2019-03-21

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

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2019-07-30

Citation on 2019-03-21

Type: Health, Deficiency: 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.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2019-07-30

Citation on 2019-03-21

Type: Health, Deficiency: Ensure medication error rates are not 5 percent or greater.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2019-05-21

Citation on 2019-03-21

Type: Health, Deficiency: 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.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2019-05-21

Citation on 2019-03-21

Type: Health, Deficiency: Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2019-05-21

Citation on 2019-03-21

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

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2019-05-21

Citation on 2019-03-21

Type: Health, Deficiency: Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2019-05-21

Citation on 2019-03-21

Type: Health, Deficiency: Provide and implement an infection prevention and control program.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2019-05-21

Citation on 2017-10-23

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

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2018-01-19

Citation on 2017-10-23

Type: Health, Deficiency: Protect each resident from all abuse, physical punishment, and involuntary separation from others.

Severity: J - Level 4: Immediate jeopardy to resident health or safety. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2017-12-08

Citation on 2017-10-23

Type: Health, Deficiency: 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.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2017-12-08

Citation on 2017-10-23

Type: Health, Deficiency: Provide housekeeping and maintenance services.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2017-12-08

Citation on 2017-10-23

Type: Health, Deficiency: Ensure each resident receives an accurate assessment by a qualified health professional.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2018-01-19

Citation on 2017-10-23

Type: Health, Deficiency: Allow residents the right to participate in the planning or revision of care and treatment.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2018-01-19

Citation on 2017-10-23

Type: Health, Deficiency: Provide necessary care and services to maintain or improve the highest well being of each resident .

Severity: G - Level 3: Actual harm that is not immediate jeopardy. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2018-01-19

Citation on 2017-10-23

Type: Health, Deficiency: Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2017-12-08

Citation on 2017-10-23

Type: Health, Deficiency: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2017-12-08

Citation on 2017-10-23

Type: Health, Deficiency: 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.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2017-12-08

Citation on 2017-10-23

Type: Health, Deficiency: Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2018-01-19

Citation on 2017-10-23

Type: Health, Deficiency: Have enough nurses to care for every resident in a way that maximizes the resident's well being.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2018-01-19

Citation on 2017-10-23

Type: Health, Deficiency: Keep accurate, complete and organized clinical records on each resident that meet professional standards.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2018-01-19

Citation on 2017-10-23

Type: Health, Deficiency: Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2018-01-19

Citation on 2021-03-19

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

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2021-05-07

Citation on 2021-03-19

Type: Health, Deficiency: 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.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2021-05-07

Citation on 2021-03-19

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

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2021-05-07

Citation on 2021-03-19

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

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2021-05-07

Citation on 2021-03-19

Type: Health, Deficiency: Ensure services provided by the nursing facility meet professional standards of quality.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2021-05-07

Citation on 2021-03-19

Type: Health, Deficiency: Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2021-05-07

Citation on 2021-03-19

Type: Health, Deficiency: Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2021-05-07

Citation on 2021-03-19

Type: Health, Deficiency: 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.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2021-05-07

Citation on 2021-03-19

Type: Health, Deficiency: Post nurse staffing information every day.

Severity: C - Level 1: No actual harm with potential for minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2021-05-07

Citation on 2021-03-19

Type: Health, Deficiency: Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2021-05-07

Citation on 2021-03-19

Type: Health, Deficiency: Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2021-05-07

Citation on 2021-03-19

Type: Health, Deficiency: Provide and implement an infection prevention and control program.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2021-05-07

Citation on 2016-08-19

Type: Health, Deficiency: Give residents a notice of rights, rules, services and charges.

Severity: C - Level 1: No actual harm with potential for minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2016-10-14

Citation on 2016-08-19

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

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2016-10-14

Citation on 2016-08-19

Type: Health, Deficiency: 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.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2016-10-14

Citation on 2016-08-19

Type: Health, Deficiency: 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.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2016-10-14

Citation on 2016-08-19

Type: Health, Deficiency: Provide housekeeping and maintenance services.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2016-10-14

Citation on 2016-08-19

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

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2016-10-14

Citation on 2016-08-19

Type: Health, Deficiency: Allow residents the right to participate in the planning or revision of care and treatment.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2016-10-14

Citation on 2016-08-19

Type: Health, Deficiency: Provide necessary care and services to maintain or improve the highest well being of each resident .

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2016-10-14

Citation on 2016-08-19

Type: Health, Deficiency: Make sure that residents receive treatments/services to maintain or improve their ability to care for themselves.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2016-10-14

Citation on 2016-08-19

Type: Health, Deficiency: Ensure that residents receive proper treatment and assistive devices to maintain their vision and hearing.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2016-10-14

Citation on 2016-08-19

Type: Health, Deficiency: Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2016-10-14

Citation on 2016-08-19

Type: Health, Deficiency: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2016-10-14

Citation on 2016-08-19

Type: Health, Deficiency: 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.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2016-10-14

Citation on 2016-08-19

Type: Health, Deficiency: Develop policies and procedures for influenza and pneumococcal immunizations.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2016-10-14

Citation on 2016-08-19

Type: Health, Deficiency: Post nurse staffing information/data on a daily basis.

Severity: C - Level 1: No actual harm with potential for minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2016-10-14

Citation on 2016-08-19

Type: Health, Deficiency: Make sure that a doctor approves a resident's admission in writing and that each resident remains under the care of a doctor.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2016-10-14

Citation on 2016-08-19

Type: Health, Deficiency: Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2016-10-14

Citation on 2016-08-19

Type: Health, Deficiency: Keep all essential equipment working safely.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2016-10-14

Citation on 2016-08-19

Type: Health, Deficiency: Give or get quality laboratory services/tests in a timely manner to meet the needs of residents.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2016-10-14

Citation on 2016-08-19

Type: Health, Deficiency: Keep accurate, complete and organized clinical records on each resident that meet professional standards.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2016-10-14


Fire Safety Citations Details

Each record details specific fire safety deficiencies found during inspections, categorized by type, severity, and whether they were corrected. Below are the severity levels and their implications:

Citation on 2019-05-02

Type: Fire Safety, Tag: 0223, Version: New

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

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2019-06-14

Citation on 2019-05-02

Type: Fire Safety, Tag: 0311, Version: New

Description: Have an enclosure around a vertical opening shaft.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2019-06-14

Citation on 2019-05-02

Type: Fire Safety, Tag: 0353, Version: New

Description: Inspect, test, and maintain automatic sprinkler systems.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2019-06-14

Citation on 2019-05-02

Type: Fire Safety, Tag: 0920, Version: New

Description: Ensure proper usage of power strips and extension cords.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2019-06-14

Citation on 2017-12-12

Type: Fire Safety, Tag: 0225, Version: New

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

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2018-01-08

Citation on 2017-12-12

Type: Fire Safety, Tag: 0321, Version: New

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

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2018-01-08

Citation on 2017-12-12

Type: Fire Safety, Tag: 0351, Version: New

Description: Install an approved automatic sprinkler system.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2018-01-08

Citation on 2017-12-12

Type: Fire Safety, Tag: 0353, Version: New

Description: Inspect, test, and maintain automatic sprinkler systems.

Severity: C - Level 1: No actual harm with potential for minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2018-01-08

Citation on 2017-12-12

Type: Fire Safety, Tag: 0374, Version: New

Description: Install smoke barrier doors that can resist smoke for at least 20 minutes.

Severity: C - Level 1: No actual harm with potential for minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2018-01-08

Citation on 2017-12-12

Type: Fire Safety, Tag: 0541, Version: New

Description: Install properly constructed and protected linen or trash chutes.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2018-01-08

Citation on 2017-12-12

Type: Fire Safety, Tag: 0923, Version: New

Description: Have proper medical gas storage and administration areas.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2018-01-08

Citation on 2016-08-16

Type: Fire Safety, Tag: 0029, Version: New

Description: Special areas constructed so that walls can resist fire for one hour or an approved fire extinguishing system.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2016-09-30

Citation on 2016-08-16

Type: Fire Safety, Tag: 0062, Version: New

Description: Automatic sprinkler systems that have been maintained in working order.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2016-09-30

Citation on 2016-08-16

Type: Fire Safety, Tag: 0144, Version: New

Description: Weekly inspections and monthly testing of generators.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2016-09-30