Safety Report: Autumn Lake Healthcare At Loch Raven
How to read this report. Every nursing home receives some citations. One citation does not mean a facility is unsafe. Look at how serious the findings were, whether the same problems keep coming back, and whether things are getting better or worse. Learn how inspections work.
Official ratings
Medicare's star ratings compare nursing homes within the same state for health inspections. A 5-star facility performed better than most in its state; a 1-star facility performed worse than most.
Stars are calculated by CMS, not by us. We do not create our own safety score.
Serious documented violations
0Immediate jeopardy citations (severity J–L)
0Actual harm citations (severity G–I)
20Requirements cited on more than one inspection
No citations at the “actual harm” or “immediate jeopardy” level in the last three inspection cycles.
Citations by topic
2Abuse, neglect & exploitation
4Infection control
9Medications & pharmacy
2Accidents & supervision
Topics use CMS's own deficiency categories; “accidents & supervision” counts tag F689 (free of accident hazards / adequate supervision). Counts cover the last three inspection cycles, including complaint investigations.
Is it getting better or worse?
More citations in the most recent cycle (30) than in the cycle before (15).
An inspection cycle is roughly one year and includes the standard inspection plus complaint investigations. Counts depend partly on how many complaint investigations occurred, so treat small changes with caution. Red bars include at least one serious citation.
Staffing and rating trends will appear as we collect monthly CMS releases. We have one month so far, so a staffing trend cannot yet be determined.
Repeat findings
These requirements were cited on more than one inspection date in the last three cycles.
| Requirement | Times cited | Inspection dates |
|---|---|---|
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. (F842) | 4 | April 30, 2026; September 11, 2025; June 13, 2023; January 10, 2019 |
| Ensure services provided by the nursing facility meet professional standards of quality. (F658) | 3 | August 24, 2026; September 11, 2025; January 10, 2019 |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. (F550) | 3 | April 30, 2026; September 11, 2025; January 10, 2019 |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. (F686) | 3 | September 11, 2025; June 13, 2023; January 10, 2019 |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. (F698) | 3 | September 11, 2025; June 13, 2023; January 10, 2019 |
| Provide appropriate treatment and care according to orders, resident’s preferences and goals. (F684) | 3 | September 11, 2025; June 13, 2023; January 10, 2019 |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. (F657) | 3 | September 11, 2025; June 13, 2023; January 10, 2019 |
| Ensure each resident receives an accurate assessment. (F641) | 3 | September 11, 2025; June 13, 2023; January 10, 2019 |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. (F656) | 2 | April 30, 2026; January 10, 2019 |
| Provide and implement an infection prevention and control program. (F880) | 2 | September 11, 2025; January 10, 2019 |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. (F812) | 2 | September 11, 2025; January 10, 2019 |
| 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. (F761) | 2 | September 11, 2025; January 10, 2019 |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. (F947) | 2 | September 11, 2025; January 10, 2019 |
| Ensure each resident’s drug regimen must be free from unnecessary drugs. (F757) | 2 | September 11, 2025; January 10, 2019 |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. (F689) | 2 | September 11, 2025; January 10, 2019 |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted (F655) | 2 | September 11, 2025; January 10, 2019 |
| 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. (F584) | 2 | September 11, 2025; January 10, 2019 |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. (F693) | 2 | June 13, 2023; January 10, 2019 |
| Assist a resident in gaining access to vision and hearing services. (F685) | 2 | June 13, 2023; January 10, 2019 |
| Provide care and assistance to perform activities of daily living for any resident who is unable. (F677) | 2 | June 13, 2023; January 10, 2019 |
Fines and enforcement
No federal fines or payment denials in the last three years.
Federal civil money penalties and Medicare/Medicaid payment denials. State-level penalties may not be included.
Complete inspection history
August 24, 2026 — 1 citation · complaint investigation
D
Ensure services provided by the nursing facility meet professional standards of quality.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F658 · complaint
April 30, 2026 — 6 citations · complaint investigation
E
Assure that each resident’s assessment is updated at least once every 3 months.
No actual harm, but potential for more than minimal harm · Pattern · Resident Assessment and Care Planning Deficiencies · F638 · complaint · corrected June 10, 2026
E
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
No actual harm, but potential for more than minimal harm · Pattern · Resident Rights Deficiencies · F550 · complaint · corrected June 10, 2026
D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F842 · complaint · corrected June 10, 2026
D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F656 · complaint · corrected June 10, 2026
D
Respond appropriately to all alleged violations.
No actual harm, but potential for more than minimal harm · Isolated · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F610 · complaint · corrected June 10, 2026
C
Post nurse staffing information every day.
No actual harm, potential for minimal harm · Widespread · Nursing and Physician Services Deficiencies · F732 · complaint · corrected June 10, 2026
September 11, 2025 — 24 citations
F
Provide and implement an infection prevention and control program.
No actual harm, but potential for more than minimal harm · Widespread · Infection Control Deficiencies · F880 · corrected October 24, 2025
F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
No actual harm, but potential for more than minimal harm · Widespread · Nutrition and Dietary Deficiencies · F812 · corrected October 24, 2025
E
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.
No actual harm, but potential for more than minimal harm · Pattern · Pharmacy Service Deficiencies · F761 · corrected October 24, 2025
D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F686 · complaint · corrected October 24, 2025
D
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
No actual harm, but potential for more than minimal harm · Isolated · Administration Deficiencies · F949 · corrected October 24, 2025
D
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
No actual harm, but potential for more than minimal harm · Isolated · Nursing and Physician Services Deficiencies · F947 · corrected October 24, 2025
D
Provide training in compliance and ethics.
No actual harm, but potential for more than minimal harm · Isolated · Administration Deficiencies · F946 · corrected October 24, 2025
D
Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.
No actual harm, but potential for more than minimal harm · Isolated · Infection Control Deficiencies · F945 · corrected October 24, 2025
D
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
No actual harm, but potential for more than minimal harm · Isolated · Administration Deficiencies · F944 · corrected October 24, 2025
D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F842 · corrected October 24, 2025
D
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.
No actual harm, but potential for more than minimal harm · Isolated · Nutrition and Dietary Deficiencies · F803 · corrected October 24, 2025
D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
No actual harm, but potential for more than minimal harm · Isolated · Pharmacy Service Deficiencies · F757 · corrected October 24, 2025
D
Observe each nurse aide's job performance and give regular training.
No actual harm, but potential for more than minimal harm · Isolated · Nursing and Physician Services Deficiencies · F730 · corrected October 24, 2025
D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F698 · corrected October 24, 2025
D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F689 · corrected October 24, 2025
D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F684 · complaint · corrected October 24, 2025
D
Ensure services provided by the nursing facility meet professional standards of quality.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F658 · complaint · corrected October 24, 2025
D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F657 · corrected October 24, 2025
D
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F655 · corrected October 24, 2025
D
Ensure each resident receives an accurate assessment.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F641 · corrected October 24, 2025
D
Protect each resident from the wrongful use of the resident's belongings or money.
No actual harm, but potential for more than minimal harm · Isolated · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F602 · corrected October 24, 2025
D
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.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F584 · corrected October 24, 2025
D
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F568 · corrected October 24, 2025
D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F550 · corrected October 24, 2025
June 13, 2023 — 14 citations
E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
No actual harm, but potential for more than minimal harm · Pattern · Quality of Life and Care Deficiencies · F684 · corrected July 14, 2023
D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F842 · corrected July 14, 2023
D
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
No actual harm, but potential for more than minimal harm · Isolated · Nutrition and Dietary Deficiencies · F806 · corrected July 14, 2023
D
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
No actual harm, but potential for more than minimal harm · Isolated · Nursing and Physician Services Deficiencies · F711 · corrected July 14, 2023
D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F698 · corrected July 14, 2023
D
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F693 · corrected July 14, 2023
D
Provide enough food/fluids to maintain a resident's health.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F692 · corrected July 14, 2023
D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F686 · corrected July 14, 2023
D
Assist a resident in gaining access to vision and hearing services.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F685 · corrected July 14, 2023
D
Provide care and assistance to perform activities of daily living for any resident who is unable.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F677 · corrected July 14, 2023
D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F657 · corrected July 14, 2023
D
Ensure each resident receives an accurate assessment.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F641 · corrected July 14, 2023
D
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F561 · corrected July 14, 2023
B
Implement a program that monitors antibiotic use.
No actual harm, potential for minimal harm · Pattern · Infection Control Deficiencies · F881 · corrected July 14, 2023
January 10, 2019 — 43 citations
F
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
No actual harm, but potential for more than minimal harm · Widespread · Nursing and Physician Services Deficiencies · F947 · corrected March 1, 2019
F
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
No actual harm, but potential for more than minimal harm · Widespread · Administration Deficiencies · F867 · corrected March 1, 2019
F
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
No actual harm, but potential for more than minimal harm · Widespread · Administration Deficiencies · F838 · corrected March 1, 2019
F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
No actual harm, but potential for more than minimal harm · Widespread · Nutrition and Dietary Deficiencies · F812 · corrected March 1, 2019
F
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.
No actual harm, but potential for more than minimal harm · Widespread · Nutrition and Dietary Deficiencies · F801 · corrected March 1, 2019
F
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
No actual harm, but potential for more than minimal harm · Widespread · Resident Assessment and Care Planning Deficiencies · F657 · corrected March 1, 2019
F
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
No actual harm, but potential for more than minimal harm · Widespread · Resident Assessment and Care Planning Deficiencies · F656 · corrected March 1, 2019
F
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
No actual harm, but potential for more than minimal harm · Widespread · Resident Assessment and Care Planning Deficiencies · F655 · corrected March 1, 2019
E
Provide and implement an infection prevention and control program.
No actual harm, but potential for more than minimal harm · Pattern · Infection Control Deficiencies · F880 · corrected March 1, 2019
E
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
No actual harm, but potential for more than minimal harm · Pattern · Resident Assessment and Care Planning Deficiencies · F842 · corrected March 1, 2019
E
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.
No actual harm, but potential for more than minimal harm · Pattern · Pharmacy Service Deficiencies · F761 · corrected March 1, 2019
E
Ensure that residents are free from significant medication errors.
No actual harm, but potential for more than minimal harm · Pattern · Pharmacy Service Deficiencies · F760 · corrected March 1, 2019
E
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.
No actual harm, but potential for more than minimal harm · Pattern · Pharmacy Service Deficiencies · F758 · corrected March 1, 2019
E
Ensure each resident’s drug regimen must be free from unnecessary drugs.
No actual harm, but potential for more than minimal harm · Pattern · Pharmacy Service Deficiencies · F757 · corrected March 1, 2019
E
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.
No actual harm, but potential for more than minimal harm · Pattern · Nursing and Physician Services Deficiencies · F726 · corrected March 1, 2019
E
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
No actual harm, but potential for more than minimal harm · Pattern · Nursing and Physician Services Deficiencies · F725 · corrected March 1, 2019
E
Provide safe, appropriate dialysis care/services for a resident who requires such services.
No actual harm, but potential for more than minimal harm · Pattern · Quality of Life and Care Deficiencies · F698 · corrected March 1, 2019
E
Provide safe and appropriate respiratory care for a resident when needed.
No actual harm, but potential for more than minimal harm · Pattern · Quality of Life and Care Deficiencies · F695 · corrected March 1, 2019
E
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
No actual harm, but potential for more than minimal harm · Pattern · Quality of Life and Care Deficiencies · F689 · corrected March 1, 2019
E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
No actual harm, but potential for more than minimal harm · Pattern · Quality of Life and Care Deficiencies · F684 · corrected March 1, 2019
E
Provide care and assistance to perform activities of daily living for any resident who is unable.
No actual harm, but potential for more than minimal harm · Pattern · Quality of Life and Care Deficiencies · F677 · corrected March 1, 2019
E
Ensure each resident receives an accurate assessment.
No actual harm, but potential for more than minimal harm · Pattern · Resident Assessment and Care Planning Deficiencies · F641 · corrected March 1, 2019
E
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.
No actual harm, but potential for more than minimal harm · Pattern · Resident Rights Deficiencies · F584 · corrected March 1, 2019
E
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
No actual harm, but potential for more than minimal harm · Pattern · Resident Rights Deficiencies · F550 · corrected March 1, 2019
D
Provide timely, quality laboratory services/tests to meet the needs of residents.
No actual harm, but potential for more than minimal harm · Isolated · Administration Deficiencies · F770 · corrected March 1, 2019
D
Ensure medication error rates are not 5 percent or greater.
No actual harm, but potential for more than minimal harm · Isolated · Pharmacy Service Deficiencies · F759 · corrected March 1, 2019
D
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
No actual harm, but potential for more than minimal harm · Isolated · Pharmacy Service Deficiencies · F756 · corrected March 1, 2019
D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
No actual harm, but potential for more than minimal harm · Isolated · Pharmacy Service Deficiencies · F755 · corrected March 1, 2019
D
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F744 · corrected March 1, 2019
D
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F693 · corrected March 1, 2019
D
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F688 · corrected March 1, 2019
D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F686 · corrected March 1, 2019
D
Assist a resident in gaining access to vision and hearing services.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F685 · corrected March 1, 2019
D
Provide activities to meet all resident's needs.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F679 · corrected March 1, 2019
D
Ensure services provided by the nursing facility meet professional standards of quality.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F658 · corrected March 1, 2019
D
Assess the resident when there is a significant change in condition
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F637 · corrected March 1, 2019
D
Prepare residents for a safe transfer or discharge from the nursing home.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F624 · corrected March 1, 2019
D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F580 · corrected March 1, 2019
D
Reasonably accommodate the needs and preferences of each resident.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F558 · corrected March 1, 2019
D
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F553 · corrected March 1, 2019
C
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.
No actual harm, potential for minimal harm · Widespread · Resident Rights Deficiencies · F625 · corrected March 1, 2019
C
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
No actual harm, potential for minimal harm · Widespread · Resident Rights Deficiencies · F623 · corrected March 1, 2019
C
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
No actual harm, potential for minimal harm · Widespread · Resident Rights Deficiencies · F577 · corrected March 1, 2019
Source: CMS Health Deficiencies dataset (data as of October 1, 2026); full inspection narratives on Medicare Care Compare