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Inspection visit

Inspection

AUTUMN LAKE HEALTHCARE AT LOCH RAVENCMS #21509027 citations on this visit
27 citations recorded

Citations

27 citations recorded*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

  • 0550GeneralS&S Dpotential for harm

    F550 - Resident Rights

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

  • 0584GeneralS&S Dpotential for harm

    F584 - Safe Environment

    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.

  • 0602GeneralS&S Dpotential for harm

    F602 - The resident has the right to be free from abuse, neglect, misappropriation of re

    Protect each resident from the wrongful use of the resident's belongings or money.

  • 0641GeneralS&S Dpotential for harm

    F641 - Accuracy of Assessments

    Ensure each resident receives an accurate assessment.

  • 0655GeneralS&S Dpotential for harm

    F655 - Comprehensive Person-Centered Care Planning

    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

  • 0657GeneralS&S Dpotential for harm

    F657 - Comprehensive Care Plans

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

  • 0658GeneralS&S Dpotential for harm

    F658 - Comprehensive Care Plans

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

  • 0684GeneralS&S Dpotential for harm

    F684 - Quality of care

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

  • 0686GeneralS&S Dpotential for harm

    F686 - Skin Integrity

    Provide appropriate pressure ulcer care and prevent new ulcers from developing.

  • 0689GeneralS&S Dpotential for harm

    F689 - Accidents

    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  • 0698GeneralS&S Dpotential for harm

    F698 - Dialysis

    Provide safe, appropriate dialysis care/services for a resident who requires such services.

  • 0730GeneralS&S Dpotential for harm

    F730 - Regular in-service education

    Observe each nurse aide's job performance and give regular training.

  • 0757GeneralS&S Dpotential for harm

    F757 - Unnecessary Drugs—General

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

  • 0761GeneralS&S Epotential for harm

    F761 - Labeling of Drugs and Biologicals

    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.

  • 0803GeneralS&S Dpotential for harm

    F803 - Menus and nutritional adequacy

    Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

  • 0812GeneralS&S Fpotential for harm

    F812 - Food safety requirements

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

  • 0842GeneralS&S Dpotential for harm

    F842 - Resident-identifiable information

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

  • 0880GeneralS&S Fpotential for harm

    F880 - Infection Control

    Provide and implement an infection prevention and control program.

  • 0944GeneralS&S Dpotential for harm

    F944 - Quality assurance and performance improvement

    Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.

  • 0945GeneralS&S Dpotential for harm

    F945 - Infection control

    Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.

  • 0946GeneralS&S Dpotential for harm

    F946 - Compliance and ethics

    Provide training in compliance and ethics.

  • 0947GeneralS&S Dpotential for harm

    F947 - Training Requirements

    Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

  • 0949GeneralS&S Dpotential for harm

    F949 - Training Requirements

    Provide behavior health training consistent with the requirements and as determined by a facility assessment.

  • 0568GeneralS&S Dpotential for harm

    F568 - Accounting and Records

    Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.

  • 0345GeneralS&S Fpotential for harm

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

  • 0712GeneralS&S Fpotential for harm

    F712 - Frequency of physician visits

    Have simulated fire drills held at unexpected times.

  • 0914GeneralS&S Fpotential for harm

    F914 - Be designed or equipped to assure full visual privacy for each

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

FAQ · About this visit

Common questions about this visit

What happened during the September 11, 2025 survey of AUTUMN LAKE HEALTHCARE AT LOCH RAVEN?

This was a inspection survey of AUTUMN LAKE HEALTHCARE AT LOCH RAVEN on September 11, 2025. The surveyor cited 27 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at AUTUMN LAKE HEALTHCARE AT LOCH RAVEN on September 11, 2025?

Yes, 27 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her right..."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

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Next steps

Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.

Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.

Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.