Autumn Lake Healthcare at Baltimore Washington

Inspectors wroteBased on observations and interviews it was determined that the facility failed to maintain a safe, clean, comfortable, homelike environment for residents. This finding was found to be evident in 13 (#4, #7, #9, #10, #20, #21, #23, #25, #26, #27, #36, #37 and #107) out of 25 resident rooms and other facility common areas reviewed for physical environment during the recertification survey.

Inspectors wroteBased on interview and record review, it was determined that the facility failed to develop and implement comprehensive care plans for residents. This finding was found to be evident in 4 (Resident # 2, #19, #31 and #136) out of 44 residents reviewed for comprehensive care plans.

Inspectors wroteBased on facility staff and Resident interviews and surveyor record review, it was determined that the facility failed to update and revise Resident care plans and failed to conduct Resident care plan meetings for 4 (Resident #2, 5, 75, and 126) out of 7 Residents reviewed for care plan timing and revision.

Inspectors wroteBased on observations, record reviews, and interviews it was determined that the facility failed to utilize professional standards during, 1) tube feeding administration, 2) pressure ulcers and 3) unnecessary medications. This was found to be evident in 4 (#1, #2, #5, and #75) out of 9 residents reviewed during the recertification survey.

Inspectors wroteBased on observations, and interviews with facility staff, it was determined that the facility failed to provide an environment that promotes resident respect and dignity. This finding was evident in 1 of 44 residents (Resident #81) selected for this survey.

Inspectors wroteBased on record review and interviews, it was determined that facility staff failed to get consent from a Resident's Responsible Party (RP) or representative related to vaccinations. This finding was evident for 2 (Resident #3 & 10) of 5 residents reviewed for vaccinations during the survey.

Inspectors wroteBased on observation and interview it was determined that the facility failed to maintain privacy for a Resident during meal delivery on the nursing units. This finding was found to be evident for 1 (Resident #75) out of 7 Residents reviewed for privacy.

Inspectors wroteBased on observation, interviews, and surveyor record reviews it was determined that the facility failed to complete assessments accurately for residents. This was found to be evident in 5 (Resident #2, #7, #10, #31 and #126) out of 44 residents reviewed for Minimum Data Set (MDS) assessments.

Inspectors wroteBased on record review and interviews it was determined that the facility failed to ensure that residents had only one Maryland Order for Life-Sustaining Treatment (MOLST) form in their paper medical record. This was evident for 1 (Residents #1) of all residents present in the sample.

Inspectors wroteBased on observations, interviews, record reviews, it was determined that the facility, staff failed to 1) ensure that the tube feeding container was labeled and 2) the facility failed to administer enteral tube feeding per manufacture's instructions. This was evident for 2 (#1 and #120) residents reviewed for tube feeding during the recertification survey.

Inspectors wroteBased on observation, interviews, facility policy review, and record review, it was determined that the facility failed to provide respiratory care consistent with professional standards for oxygen administration. This was found evident of 1 (Resident #8) out of 2 residents reviewed for respiratory care during the survey.

Inspectors wroteBased on observations, record reviews, and staff interviews, it was determined that the facility failed to provide appropriate pain management medication for resident 31. This was evident for 1 of 1 residents reviewed for pain management during the recertification surveyOn 2/8/2026 at 9:09 AM, the surveyor interviewed Resident #31. During that interview the resident stated that they had been diagnosed with Rheumatoid Arthritis approximately 20 years ago and had been in constant pain since. The resident stated that they were not receiving their pain medication correctly. On 2/9/2026 at 10:45 AM , the surveyor reviewed Resident #31 's medical records. The review revealed that Resident #31 had a standing order for Hydrocodone-Acetaminophen Oral Tablet 7.5-325 mg to be given every 8 hours. [...]

Inspectors wroteBased on record review and interviews with facility staff and family, it was determined that the primary medical provider failed to review the total program of care when the plan when a code status changed. This was found evident for 1 (Resident #1) out of 44 residents selected for review during the survey.

Inspectors wroteBased on medical record review and interview, it was determined that the facility failed to address medication regimen review (MRR) recommendations made by the consulting pharmacist. This was found to be evident for 2 (#35 and #75) out of 5 residents reviewed during the recertification survey.

Inspectors wroteBased on record reviews and interviews, it was determined that the facility staff failed to adequately monitor a resident's drug regimen which allowed unnecessary duplicate orders for medications. This finding was evident for 1 (Resident #8) of 5 residents reviewed for unnecessary medications during the survey.

Inspectors wroteBased on observations and interviews with staff, it was determined that the facility failed to properly store a Resident's medication. This was found evident on 2 of 3 observations for Resident #8.

Inspectors wroteBased on interview, observation and record review it was determined that the facility failed to follow up on dental care recommendations. This was found to be evident for 1 (#131) of 1 residents reviewed during the recertification survey.

Inspectors wroteBased on observation, an interview and record review the facility failed to maintain proper infection control procedures, specifically regarding staff's use of beard nets in the kitchen. This was evident during the follow-up tour of the kitchen.

Inspectors wroteBased on facility staff interviews and surveyor record reviews it was determined that the facility failed to maintain Resident medical records that were accurate and reflective of the Residents' care. This finding was found to be evident in 2 (Resident #19 and #126) out of 7 Residents reviewed for Resident records - identifiable information.

Inspectors wroteBased on observations, interviews and record reviews, it was determined that the facility failed to 1) maintain infection prevention control practices for the storage of linen and 2) have a process to identify residents who required transmission based precautions. This was found to be evident in 2 (27 and 112) out of 2 rooms and 1 out of 3 nursing units reviewed for infection prevention and control during the recertification survey.

Inspectors wroteBased on observation and staff interview it was determined the facility failed to assure that a heating unit and oxygen concentrator were fully operational while in use in Resident care areas. This was found evident in 1 (Resident # 122's room) out of 55 rooms reviewed and 1 (Resident #8) out of 2 residents reviewed for oxygenation.

Inspectors wroteBased on observation and interview it was determined the facility failed to 1) ensure a resident had access to the call bell and 2) ensure a call device was accessible in each shower. This was evident for 2 of 3 observations for (Resident #1) and also during the environmental tour of the facility conducted during the recertification survey.

Inspectors wroteBased on observation and interview it was determined that the facility failed to maintain a safe, functional, sanitary and comfortable environment for the residents, facility staff and the public. This was found to be evident in the facility reviewed for a safe, functional, sanitary and comfortable physical environment.

Inspectors wroteBased on interview and observation, it was determined that the facility failed to keep the premises free of pests. This deficient practice had the potential to impact all residents.

Inspectors wroteBased on record reviews and interviews it was determined that the facility staff failed to ensure maintenance care was provided to a resident's tube feeding device. This was evident for 1 (#8) of 1 resident reviewed for tube feedings.

Inspectors wroteBased on reviews of a complaint and a medical record, and interviews with facility staff, it was determined that the facility failed to notify the resident's physician regarding the incorrect documentation of a Resident's weight. This was evident for 1 (Resident #6) of 8 residents reviewed during a complaint survey.

Inspectors wroteBased on complaint, observations of a resident's wound care, and staff interview, it was determined that the facility staff failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. This was observed for 1 (Resident #6) of 8 complaints reviewed during a complaint survey.

Inspectors wroteBased on complaint, reviews of clinical records and all pertinent administrative records, reviews of a hospital record, and staff interview, it was determined that the facility staff failed to immediately report an allegation of suspected resident abuse to the administrator and the State Survey Agency within 2 hours. This was evident for 1 (Resident #4) of 8 residents reviewed during a complaint survey.

Inspectors wroteBased on medical record review, facility investigation review, and staff interview, it was determined that the facility failed to thoroughly investigate a resident's allegation of being physically injured by nursing staff members. This was evident for 1 (Resident #4) of 8 residents reviewed during the complaint survey.

Inspectors wroteBased on complaint, reviews of all pertinent documentation and clinical records, and staff interview, it was determined that facility staff failed to implement parts of a comprehensive care plan for a resident. This was evident for 2 (Resident #6, #7) of 8 residents reviewed during a complaint survey.

Inspectors wroteBased on reviews of a complaint and a medical record, and interviews with facility staff, it was determined that the facility failed to maintain or improve a resident's nutritional status after having a feeding tube placed. This was evident for 1 (Resident #6) of 8 residents reviewed during a complaint survey.

Inspectors wroteBased on reviews of closed and active medical records, reviews of all pertinent administrative records, and staff interviews, it was determined that the facility failed to have a system in place to ensure clinical records were complete and accurately documented. This was found to be evident for 2 (Residents #1, #4) of 8 residents reviewed during the complaint survey.

Inspectors wroteBased on complaint, observation, reviews of all pertinent documents and clinical records, and resident interview, it was determined that the facility staff failed to ensure that a resident's bed could adequately meet the resident's needs. This was evident for 1 (Resident #6) of 8 residents reviewed during a complaint survey.

Inspectors wroteBased on the surveyor's observation and interview with staff, it was determined that the facility failed to ensure that it had qualified staff with the appropriate competencies and skill sets to carry out food and nutrition services. This has the potential to affect all residents.

Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to: ensure an effective process was in place to report pest issues, ensure pest issues were effectively and timely managed, and ensure the environment was free from pests. This was evident during the surveyor's review of complaints and during the facility's recertification/complaint survey and has the potential to affect all residents.

Inspectors wroteBased on observation and interview it was determined the facility failed to maintain a clean, homelike environment. This was evident throughout the facility in some resident rooms and common areas during the recertification/complaint survey.

Inspectors wrote1c) On 8/29/2024 at 10:50 AM, review of Facility Reported Incident (FRI), MD00182377, revealed that Resident #158's daughter stated since she reported a CNA (Certified Nursing Assistant) was rough with Resident #158, the resident has been neglected and was not being changed timely. Further review of the facility investigation report of the incident revealed staff training on abuse done in February 2022 after the incident and staff sign-in sheet on file. Staff and resident interviews were on file. However, the CNA mentioned in the FRI was not identified and there was no statement from her/him regarding the incident. On 8/29/2024 at 1:10 PM, additional review of the investigation report of the FRI revealed an email from the then Director of Nursing dated 2/15/2022 at 9:43 AM which stated that I made the daughter aware on Sunday when I was here, and she insisted on talking to me. [...]

Inspectors wroteBased on a review of resident medical records and interviews with residents and facility staff, it was determined that the facility failed 1) to provide care timely when the resident had injuries after a fall, 2) to administer medication when the resident had a sore in the mouth 3) to follow up with resident with a new change in condition, 4) to document blood sugar as ordered and to implement an order for pressure relief, and 5) to ensure residents receive medications as ordered by the physician. This was evident for 5 (Resident #187, #175, #190, #49, and #160) ) of 78 residents reviewed during the recertification/complaint survey. 1) On 8/28/24 at 11:09 AM, the surveyor reviewed complaints. The review revealed that a complainant reported a few concerns regarding Resident #187's care: [...]

Inspectors wroteBased on observation and interview with residents and staff, it was determined that the facility failed to promote care of residents in a manner and in an environment that maintains or enhances each resident's dignity and respect by failing to serve residents seated at the same table food at the same time. This was identified for two residents (Resident #356, #90) when observing dining during a recertification/complaint survey.

Inspectors wroteBased on a review of complaints, medical record reviews, and interviews with complainants and staff, it was determined that the facility staff failed to protect the privacy of residents' medical information by giving a resident's medication to a different resident upon their discharge. This was evident one (Resident #161) of 78 residents reviewed during a recertification/complaint survey.

Inspectors wroteBased on record review and interview it was determined the facility staff failed to 1) report an allegation of abuse within 2 hours of the allegation to the regulatory agency, the Office of Health Care Quality (OHCQ), 2) failed to report residents' injuries of unknown origin to OHCQ, and 3) failed to submit initial reports of the facility-reported incidents to OHCQ. This was evident for 2 (Resident #155, #158) of 13 residents reviewed for abuse and 4 (Residents #187, #162, #170, #171) of 14 residents reviewed for complaints and self-reported incidents during a recertification/complaint survey.

Inspectors wroteBased on medical record review and staff interviews it was determined the facility failed to notify the resident/resident representative (RP) in writing of a transfer/discharge of a resident along with the reason for the transfer. This was evident for 1 (#49) of 4 residents reviewed for hospitalization during a recertification/complaint survey.

Inspectors wroteBased on the review of medical records and staff interviews, it was determined that the facility failed to provide the resident and or their representative with a summary of the baseline care plan. This was evident for 1 (Resident # 10) of 1 resident reviewed for baseline care plans, during a recertification/complaint survey.

Inspectors wroteBased on the review of medical records and staff interviews, it was determined that the facility failed to develop and implement a comprehensive resident-centered care plan, that includes measurable objectives, interventions and timeframes to meet a resident's medical, nursing, mental and psychosocial needs. This was evident for four (Resident # 191, #7, #254, #10) out of 78 residents reviewed for during the recertification/complaint survey.

Inspectors wroteBased on observation, record review and interviews, it was determined that the facility failed to revise and update resident's comprehensive care plans. This was evident for 2 (Resident #46, #10) of 78 residents reviewed during a recertification/complaint survey.

Inspectors wroteBased on observation, interview and record review, it was determined that the facility staff failed to follow professional standards of nursing practice when administering medications to residents by 1) not verifying current order before administering, 2) not documenting controlled medications use on the count sheet and Medication Administration Records, and 3) mishandling Insulin pen. This was evident for 4 (Resident #86, #66, #21, #8) of 5 residents reviewed for medication administration during the recertification/complaint survey.

Inspectors wroteBased on observation, record review and interview, the facility failed to meet the resident's rehabilitation needs and failed to provide the necessary care which the facility had to ensure and not diminish the resident's functional abilities and skills. This was evident for 2 (Residents #41 & #65) of 3 residents reviewed for rehabilitation and restorative services during a recertification/complaint survey.

Inspectors wroteBased on a review of the complaint, record review, and interview, it was determined that the facility failed to provide appropriate care and treatment to a resident with a pressure ulcer. This was evident for 1 (Resident #182) of 9 residents reviewed for pressure ulcers during a recertification/complaint survey.

Inspectors wroteBased on observation and interview it was determined the facility failed to ensure a resident room was maintained free from accident hazards. This was evident for one( Resident #7) out of one resident reviewed for resident to resident interaction duing a recertification/complaint survey.

Inspectors wroteBased on medical record review and interview it was determined that the facility failed to 1) ensure a resident admitted to the facility with a suprapubic catheter received care and develop a care plan which included the use of the catheter and associated interventions, 2) evaluate a foley catheter when a resident had repeated clogged foley catheter issues, and 3) ensure a resident with a foley catheter had a medical order for care of the catheter. This was evident for 3 (Resident #156, #254 and #154) of 4 residents reviewed for bowel and bladder incontinence during the recertification/complaint survey.

Inspectors wroteBased on observation, medical record review, and interview it was determined that the facility staff failed 1) to maintain the resident's meal proportions to assure a desirable body weight. The inadequate meal proportions resulted in severe weight loss of more than 12% in 6 months, and 2) to notify the Physician regarding the resident's significant weight loss and revised their care plan. This was evident for 2 (Resident #60 and #175) of 5 residents reviewed for nutrition during a recertification/complaint survey.

Inspectors wroteBased on observation, record review, and interview, it was determined that the facility failed to provide appropriate treatment and services to residents receiving tube feeding. This was evident for one (Resident #88) of three residents reviewed for tube feeding during the recertification/complaint survey.

Inspectors wroteBased on resident interview, staff interview, and medical record review, it was determined that the facility failed to ensure that pain management is provided to residents who require such services. This was evident for two (Residents #161, #10) out of four residents reviewed for pain management during a recertification/complaint survey.

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility staff failed to ensure a registered nurse had the skills to provide necessary care for residents who needed insulin. This was evident for 1 (Registered Nurse #9) of 3 Nurses observed for medication administrations during a recertification/complaint survey.

Inspectors wroteBased on a review of employee records and interviews, it was determined that the facility staff failed to conduct performance reviews of Geriatric Nursing Assistants (GNAs) at least once every 12 months. This was evident for 1 (GNA #30) of 3 randomly selected GNAs' records reviewed for annual training requirements during the recertification/complaint survey.

Inspectors wroteBased on record review and interview, it was determined that the facility failed to ensure that drug records were maintained in a manner that accounted for all controlled drugs and allowed reconciliation of dispensed and administered medication. This was evident for 3 (Resident #86, #66, and #21) of 5 residents reviewed for medication administration during a recertification/complaint survey.

Inspectors wroteBased on record review and staff interviews, it was determined that the facility failed to follow up on a pharmacy recommendation for a resident. This was evident for 1 (#46) of 5 residents reviewed for unnecessary medication during a recertification/complaint survey.

Inspectors wroteBased on medical record review and interview, it was determined the facility staff failed to follow physician orders by administering as needed (PRN) pain medication outside the prescribed parameters. By failing to follow the prescribed parameters for the medication administration, the resident was given an unnecessary medication. This was identified for 1 (#86) of 5 residents reviewed for unnecessary medications during a recertification/complaint survey.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure monitoring for side effects of psychotropic medication use. This was evident for one (Resident #254) out of twenty-two residents reviewed for abuse during the facility's recertification/complaint survey.

Inspectors wroteBased on observation and interview it was determined the facility failed 1) to ensure the secure storage of medications, 2) to ensure that medications were properly labeled and stored, and 3) to provide safe and secure storage to minimize loss or diversion of narcotic medications. This was evident for three residents (Resident #31, #56, #79) observed to have medications in their room, 2 (station 2 and station 3) of 3 medication rooms, 3 (station 3 cart 1, station 1 cart 3 and station 2 cart 1) of 6 medication carts, and 2 residents (Resident #170 and #162) reviewed for safe medication storage and labeling during the facility's recertification/complaint survey.

Inspectors wroteBased on the surveyor's observation, interview with facility staff, and medical record review, the facility failed to maintain medical records on each resident in accordance with professional standards and practices that are: i) Complete; (ii) Accurately documented; (iii) Readily accessible; and (iv) Systematically organized. This was evident for three residents (Resident #187, #31, # 10) out of 78 residents reviewed during the recertification/complaint survey.

Inspectors wroteBased on observation and interview, it was determined the facility failed to ensure staff performed hand hygiene prior to administering medications and used appropriate handling to prevent infection. This was evident for one (a Licensed Practical Nurse #13) out of three nurses observed administering medications during the recertification/complaint survey. On 8/27/24 at 9:11 AM, during medication administration, the Licensed Practical Nurse (LPN #13) was observed not performing hand hygiene when he/she prepared the medications of Resident #21. LPN #13 was also observed poking the blister pack of medication with a pen to get the tablet. The surveyor asked LPN #13 if it was standard practice in the facility to use a pen to get the medications out of a blister pack; he/she stated that he had a hard time opening the pack, so he/she had to find a way. [...]

Inspectors wroteBased on observation and interview it was determined the facility failed to ensure two handrails were firmly secured. This was evident during the surveyor's environmental tour during the facility's recertification/complaint survey.

Inspectors wroteBased on medical record review and interview with facility staff, it was determined that the facility failed to complete a discharge summary on a resident to include a recapitulation of the resident's stay in the facility. This was evident in 3 of 45 residents (Resident #80, #81, #82) reviewed during the investigative portion of the survey.

Inspectors wroteBased on surveyor observation and staff interview, it was determined that the facility failed to have adequate ventilation to ensure good air circulation to keep all parts of the facility odor free. This was evident during the initial tour of the facility.

Inspectors wroteBased on administrative record review and interviews with facility staff it was determined the facility failed to thoroughly investigate allegations of abuse. This was evident for when 2 facility reported incidents (Resident #57 and #181) reviewed during the survey.

Inspectors wroteBased on medical record review and interview with staff it was determined that the facility failed to have a system in place to ensure the resident, or their responsible party, received written notification of a transfer to the hospital, including appeal rights and Ombudsman contact information. This was found to be evident for 1 out of 4 residents (Resident #55) reviewed for hospitalization.

Inspectors wroteBased on medical record review and interview with the facility staff it was determined that the facility failed to ensure the Minimum Data Set (MDS) assessments accurately reflected the resident's status as evidenced by: 1) failure to accurately document a residents discharge location and 2) failure to correctly assess a residents dental status. This was evident for 2 out of 45 residents (Resident #81, #18) reviewed during the investigation stage of the survey.

Inspectors wroteBased on medical record review, and interview with facility staff it was determined that the facility failed to develop person-centered individualized comprehensive care plan as evidenced by failure to develop a care plan to address resident activities. This was evident for 1 out of 45 residents (Resident #230) reviewed during the investigation stage of the survey.

Inspectors wroteBased on observations, interview and medical record review it was determined the facility failed to provide activity services as indicated in accordance to the resident's care plan and assessments. This was found to be evident for 2 out of 6 residents (Resident #36, and #230) reviewed for activities during the survey.

Inspectors wroteBased on observation and interview, the facility staff failed to apply TED stockings and to elevate legs on a pillow when in bed for Resident #18 this was evident for 1 of 45 residents during the investigative portion of the survey.

Inspectors wroteBased on medical record review and staff interview it was determined the facility failed to provide supervision to Resident #18 who was known to smoke cigarettes. This was evident for 1 of 45 residents reviewed for safety/supervision during this complaint survey.

Inspectors wroteBased on administrative record review, medical record review and interview with facility staff, it was determined that the facility 1) failed to properly manage and administer pain medication to a resident who was noted to have pain and 2) failed to initiate pain medication for a resident that was assessed as having pain on his/her daily pain assessment in addition to having pressure ulcers and pain medication ordered on a hospital discharge summary. This was evident in 2 of 6 residents reviewed for pain (Resident #181, and #183) during the review of a complaint and during the review of 1 of 2 residents (Resident #181) selected for the review of pain during the survey.

Inspectors wroteBased on record review, observation and interview, it was determined the facility staff failed to obtain a medication error rate below 5%. Review of medication pass on 10/15/19 at 8:30 AM revealed the medication administration error rate was 5.71% for Resident (#330). This was evident for 2 out of 35 opportunities for error and 1 out of 4 residents observed for medication administration.

Inspectors wroteBased upon resident interview, staff interview and medical record review it was determined that facility staff failed to assist a resident in obtaining routine and emergency dental care. This was evident for 1 of 45 residents (Resident #18) reviewed during the investigative portion of the survey.

Inspectors wroteBased on review of 6 newly hired employees, it was determined the facility staff failed to screen those 6 employees for MMR and Varicella. This was evident for 6 of 6 employee records (Staff #4, #5 #6, #7, #8, #9) reviewed during the annual survey.

Inspectors wroteBased on observation, resident and staff interviews and review of the facility pest control records, it was determined that the facility staff failed to maintain an effective pest control program, specifically concerning fly control involving Resident's #18 but has the ability to impact all residents, staff and visitors in the facility.