Autumn Lake Healthcare at Loch Raven

In the surveyor’s words

From the most serious findings on record at Autumn Lake Healthcare at Loch Raven, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Sep 11, 2025

  Number of residents sampled: Number of residents cited: Based on observations and staff interviews, it was determined that the facility failed to ensure food items were stored to maintain the integrity of the specific items. This was evident for 1) the initial observation of the kitchen upon facility entry, and 2) 1 of 1 observation of the second floor nourishment room. This failure has the potential to affect all residents. The findings include: 1) On 09/04/2025 at 8:03 AM, an initial observation of kitchen dry storage room revealed a bag of soft tortillas which were opened and unlabeled, a large box of rice which was opened, unsealed, and unlabeled, a large box of food thickener which was opened, unsealed, and unlabeled, and a packet of ranch dressing seasoning which was opened and… […]

• No harm, potential for more than minimal, widespreadF880Sep 11, 2025

  Based on observations, medical record reviews, and staff interviews, it was determined that the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. This was found to be evident during the recertification survey. This deficiency has the potential to affect all residents.The findings include: 1) On 9/04/2025 at 8:07 AM, an observation was made of Resident #102. Resident #102's urinary catheter bag was observed to be lying on the floor beside the resident's bed. On 9/04/2025 at 8:09 AM, an interview was conducted with Staff #3. […]

• No harm, potential for more than minimal, patternF550Apr 30, 2026

  Based on medical record review and facility staff interview, the facility staff failed ensure that residents, who are unable to ambulate using stairs, are able to exercise their right to have visitors during their stay when the facility's only elevator malfunctioned. This was evident for all residents who have 2nd floor rooms and are unable to ambulate the stairs. These residents were reviewed during a complaint survey. The findings include: Review of complaint 2981882 on 4/29/26 at 1:30pm and complaint 2970515 on 4/29/26 at 2:03pm revealed family members were unable to visit their family members in the facility when the facility's only elevator malfunctioned. […]

• No harm, potential for more than minimal, patternF638Apr 30, 2026

  Based on medical record review and interview, facility staff failed to assess residents (#1, #11, #13, #15, and #16) for smoking safety at least once every three (3) months between comprehensive assessments. This was evident for 5 out of 10 residents reviewed for smoking safety during the facility's complaint survey. Findings include: Surveyor review of incident report 2975971 on 4/27/26 at 9:15am revealed the facility's only elevator was inoperative from 3/28/26 - 4/23/26. On 4/27/26 at 11:30am, the surveyor reviewed the facility's investigation and emergency plan for the facility when the elevator is inoperative. The investigation included a timeline of events and documentation on actions taken to address the needs of the residents affected. […]

• No harm, potential for more than minimal, patternF761Sep 11, 2025

  Based on a tour of the second floor medication storage room and staff interview, it was determined that the facility failed to discard expired supplies. This was evident for 1 of 1 medication storage rooms that were reviewed during the annual survey. The findings include: On [DATE] at 10:57 AM, a tour of the medication storage room on the second floor revealed expired supplies. The expired items that were found: 6 tubes of antifungal cream with 1% clotrimazole that expired 5/2024. 1 box of 29 xeroform gauze dressings with 3% bismuth tribromophenate and petroleum that expired on [DATE]. 1 box of 47 oil emulsion dressings that expired on [DATE]. 1 box of 5 duoderm dressings that expired on [DATE]. 4 tubes of dynagel moisturizing wound hydrogel with vitamin E and aloe vera. […]