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Nursing Home Inspect > Maryland > Frederick County Data as of October 2024

    Autumn Lake Healthcare At Ballenger Creek

    For profit - Limited Liability company  ·  347 Ballenger Drive, Frederick, MD 21701  ·  See home’s Medicare page

    Affiliated With Autumn Lake Healthcare
    People or companies with an ownership interest in or managerial control of this home, according to CMS data.
    3.93
    Nurse hours/resident/day
    Reported total nurse staffing hours per resident per day.
    State Average: 3.9
    42.4%
    Nurse turnover
    The percentage of nursing staff who stopped working at the home over a 12-month period.
    State Average: 45.5%
    130
    Certified beds
    Qualifying beds in the certified provider or supplier facility.
    117
    Average residents/day
    Average number of residents based on daily census.
    Direct owners are the layer of ownership closest to the nursing home while indirect owners have a stake in the nursing home but are further removed, like a company that owns the direct owner of a home. All owners listed below are people or companies who have at least a 5% stake in the nursing home. Entities with “managerial control” are those who conduct the day-to-day operations of the nursing home.
    Direct owners
    347 Ballenger Holdco Llc
    Indirect owners
    A&R Stern Family Md1 Holdings Llc
    Hatzlacha Rabbah Llc
    Aryeh Stern
    Managerial control
    No information available
    Managing employee(s)
    Christopher Coronado since May, 2021

    Inspection Reports

    53

    total deficiencies

    4

    infection-related deficiencies

    This home violated federal standards protecting residents from the spread of infections.

    Inspection reports document deficiencies, which are nursing homes’ failures to meet care requirements. The Centers for Medicare and Medicaid Services releases the last three standard inspection reports, as well as the last 36 months of complaint and infection-control reports.
    Nov 15, 2022
    Complaint report
    1 deficiency
    $81,026 Fine
    1 Payment Suspension
    D
    Full report
    Nutrition and Dietary Deficiency — F0809
    Failure to: 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.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Nov 15, 2022
    Standard report
    24 deficiencies
    (1 infection)

    This report includes a citation for violating federal standards protecting residents from the spread of infections.
    $81,026 Fine
    1 Payment Suspension
    B

     to J
    J
    Full report
    Pharmacy Service Deficiency — F0760
    Failure to: Ensure that residents are free from significant medication errors.
    Severity
    Immediate jeopardy to resident health or safety
    Scope
    Few people affected
    Seriousness
    J
    Quality of Life and Care Deficiency — F0689
    Failure to: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    Severity
    Actual harm that is not immediate jeopardy
    Scope
    Few people affected
    Seriousness
    G
    Nursing and Physician Services Deficiency — F0730
    Failure to: Observe each nurse aide's job performance and give regular training.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Many people affected
    Seriousness
    F
    Freedom from Abuse, Neglect, and Exploitation Deficiency — F0607
    Failure to: Develop and implement policies and procedures to prevent abuse, neglect, and theft.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Many people affected
    Seriousness
    F
    Resident Assessment and Care Planning Deficiency — F0656
    Failure to: Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Some people affected
    Seriousness
    E
    Resident Assessment and Care Planning Deficiency — F0657
    Failure to: Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Some people affected
    Seriousness
    E
    Quality of Life and Care Deficiency — F0677
    Failure to: Provide care and assistance to perform activities of daily living for any resident who is unable.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Some people affected
    Seriousness
    E
    Quality of Life and Care Deficiency — F0679
    Failure to: Provide activities to meet all resident's needs.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Some people affected
    Seriousness
    E
    Quality of Life and Care Deficiency — F0684
    Failure to: Provide appropriate treatment and care according to orders, resident's preferences and goals.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Some people affected
    Seriousness
    E
    Freedom from Abuse, Neglect, and Exploitation Deficiency — F0610
    Failure to: Respond appropriately to all alleged violations.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Resident Assessment and Care Planning Deficiency — F0641
    Failure to: Ensure each resident receives an accurate assessment.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Nursing and Physician Services Deficiency — F0711
    Failure to: Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Resident Assessment and Care Planning Deficiency — F0842
    Failure to: Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Resident Rights Deficiency — F0578
    Failure to: Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Resident Rights Deficiency — F0585
    Failure to: 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.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Resident Assessment and Care Planning Deficiency — F0655
    Failure to: Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Quality of Life and Care Deficiency — F0680
    Failure to: Ensure the activities program is directed by a qualified professional.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Pharmacy Service Deficiency — F0756
    Failure to: Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Pharmacy Service Deficiency — F0758
    Failure to: 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
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Administration Deficiency — F0865
    Failure to: Have a plan that describes the process for conducting QAPI and QAA activities.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Infection Control Deficiency — F0880
    Failure to: Provide and implement an infection prevention and control program.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Freedom from Abuse, Neglect, and Exploitation Deficiency — F0600
    Failure to: Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Nursing and Physician Services Deficiency — F0732
    Failure to: Post nurse staffing information every day.
    Severity
    No actual harm, with potential for minimal harm
    Scope
    Many people affected
    Seriousness
    C
    Resident Rights Deficiency — F0573
    Failure to: Let each resident or the resident's legal representative access or purchase copies of all the resident's records.
    Severity
    No actual harm, with potential for minimal harm
    Scope
    Some people affected
    Seriousness
    B
    Feb 9, 2022
    Infection report
    2 deficiencies
    (2 infection)

    This report includes a citation for violating federal standards protecting residents from the spread of infections.
    D

     to E
    E
    Full report
    Infection Control Deficiency — F0883
    Failure to: Develop and implement policies and procedures for flu and pneumonia vaccinations.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Some people affected
    Seriousness
    E
    Infection Control Deficiency — F0887
    Failure to: Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Oct 22, 2021
    Complaint report
    1 deficiency
    D
    Full report
    Quality of Life and Care Deficiency — F0684
    Failure to: Provide appropriate treatment and care according to orders, resident's preferences and goals.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Nov 19, 2018
    Standard report
    10 deficiencies
    (1 infection)

    This report includes a citation for violating federal standards protecting residents from the spread of infections.
    D

     to E
    E
    Full report
    Pharmacy Service Deficiency — F0757
    Failure to: Ensure each resident's drug regimen must be free from unnecessary drugs.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Some people affected
    Seriousness
    E
    Administration Deficiency — F0867
    Failure to: Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Some people affected
    Seriousness
    E
    Resident Assessment and Care Planning Deficiency — F0641
    Failure to: Ensure each resident receives an accurate assessment.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Resident Assessment and Care Planning Deficiency — F0656
    Failure to: Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Resident Assessment and Care Planning Deficiency — F0657
    Failure to: Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Quality of Life and Care Deficiency — F0684
    Failure to: Provide appropriate treatment and care according to orders, resident's preferences and goals.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Quality of Life and Care Deficiency — F0689
    Failure to: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Pharmacy Service Deficiency — F0761
    Failure to: 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
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Resident Assessment and Care Planning Deficiency — F0842
    Failure to: Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Infection Control Deficiency — F0880
    Failure to: Provide and implement an infection prevention and control program.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Apr 18, 2018
    Standard report
    15 deficiencies
    D

     to E
    E
    Full report
    Resident Rights Deficiency — F0584
    Failure to: 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
    No actual harm, with a potential for more than minimal harm
    Scope
    Some people affected
    Seriousness
    E
    Resident Assessment and Care Planning Deficiency — F0656
    Failure to: Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Some people affected
    Seriousness
    E
    Resident Assessment and Care Planning Deficiency — F0657
    Failure to: Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Some people affected
    Seriousness
    E
    Quality of Life and Care Deficiency — F0690
    Failure to: Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Some people affected
    Seriousness
    E
    Pharmacy Service Deficiency — F0761
    Failure to: 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
    No actual harm, with a potential for more than minimal harm
    Scope
    Some people affected
    Seriousness
    E
    Resident Assessment and Care Planning Deficiency — F0842
    Failure to: Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Some people affected
    Seriousness
    E
    Administration Deficiency — F0867
    Failure to: Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Some people affected
    Seriousness
    E
    Resident Rights Deficiency — F0558
    Failure to: Reasonably accommodate the needs and preferences of each resident.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Resident Assessment and Care Planning Deficiency — F0636
    Failure to: Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Resident Assessment and Care Planning Deficiency — F0641
    Failure to: Ensure each resident receives an accurate assessment.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Quality of Life and Care Deficiency — F0676
    Failure to: Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Quality of Life and Care Deficiency — F0685
    Failure to: Assist a resident in gaining access to vision and hearing services.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Quality of Life and Care Deficiency — F0689
    Failure to: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Nursing and Physician Services Deficiency — F0710
    Failure to: Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Nutrition and Dietary Deficiency — F0801
    Failure to: 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.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D

    Penalties

    $81K

    total fines

    1

    payment suspension

    A nursing home receives a penalty, either a fine or payment suspensions, when it has a serious health citation or fails to fix a citation. Fines may be imposed once per citation or regularly until the nursing home corrects the citation. Fines not associated with inspection reports can include fines for not reporting COVID-19 data or not complying with infection-control requirements. Payment suspensions are when the government stops payments to the nursing home until an issue is fixed. The Centers for Medicare and Medicaid Services releases the last three years of penalty information.
    Nov 15, 2022
    $81,026 fine
    1 Payment Suspension