Federal Nursing-Home Survey Record
AUTUMN LAKE HEALTHCARE AT BALLENGER CREEK
Does AUTUMN LAKE HEALTHCARE AT BALLENGER CREEK have a federal violation or abuse history?
According to the public federal record on file with the Centers for Medicare & Medicaid Services (CMS), AUTUMN LAKE HEALTHCARE AT BALLENGER CREEK (CCN 215001), in FREDERICK, MD, has federal inspection findings on its record.
In its current inspection cycle, CMS cited the facility for 29 deficiencies; the most serious carries scope/severity F on CMS's A–L scale — CMS's "potential for harm" tier, below actual harm. The most recent federal survey on file is dated 2025-06-30. Citations from earlier inspection cycles appear in the dated timeline below as historical findings, not current ones. This page restates the federal record as published by CMS and draws no conclusion of its own. Federal nursing-home surveys are conducted on a recurring cycle by state survey agencies acting on CMS's behalf, and the figures on this page are compiled from CMS's published provider data, as on file with CMS; the federal record may understate what actually occurred, and inspection findings are point-in-time survey results, not a determination that any specific resident was harmed.
The Federal Record
The most recent federal inspection on file records no actual-harm or immediate-jeopardy citations for this facility.
Below is this facility's federal survey record as on file with CMS.
Scope & Severity — current cycle
Overall CMS star rating: this facility vs the CMS-published state average
This facility: 1 · CMS state average: 3.1
Deficiency timeline — full federal history
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.
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Respond appropriately to all alleged violations.
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
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.
Provide activities to meet all resident's needs.
Provide care and assistance to perform activities of daily living for any resident who is unable.
Respond appropriately to all alleged violations.
Ensure that residents are free from significant medication errors.
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Assess the resident when there is a significant change in condition
Ensure each resident receives an accurate assessment.
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Provide and implement an infection prevention and control program.
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.
Provide safe, appropriate pain management for a resident who requires such services.
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.
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
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.
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Reasonably accommodate the needs and preferences of each resident.
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Keep all essential equipment working safely.
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
31 citations from earlier inspection cycles — historical, not current (expand)
Ensure that residents are free from significant medication errors.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Observe each nurse aide's job performance and give regular training.
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Provide care and assistance to perform activities of daily living for any resident who is unable.
Provide activities to meet all resident's needs.
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
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.
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.
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Respond appropriately to all alleged violations.
Ensure each resident receives an accurate assessment.
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Ensure the activities program is directed by a qualified professional.
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
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.
Have a plan that describes the process for conducting QAPI and QAA activities.
Provide and implement an infection prevention and control program.
Post nurse staffing information every day.
Let each resident or the resident's legal representative access or purchase copies of all the resident's records.
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Ensure each resident receives an accurate assessment.
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.
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Provide and implement an infection prevention and control program.
Document what happened
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