Autumn Lake Healthcare at Calvert Manor

Inspectors wroteBased on interviews and resident record review, it was determined that the facility failed to prevent an avoidable accident with injury to Resident #15 during a transfer from the wheelchair to the bed. The facility failed to implement interventions, including adequate supervision that was consistent with the resident's needs, care plan and current professional standards of practice to reduce the risk of an accident. As a result, Resident #15 suffered a fall with harm (femur fracture). This was evident for 1 (#15) of 3 residents reviewed for accidents during the recertification survey.

Inspectors wroteBased on observation, facility policy review, and staff interview, it was determined that the facility failed to maintain nutrition room refrigerators in a sanitary manner as evidenced by the facility failing to maintain safe cold-storage temperatures and failing to discard expired resident food. This was found to be evident in 1 (South Unit) of 2 unit nutrition rooms observed. This deficient practice created the potential for foodborne illness.

Inspectors wroteBased on observations and staff interviews, it was determined that the facility failed to ensure that the residents' call bell system was functioning properly as evidenced by the call bell system monitor being turned off at the nurses' station. This was evident for observations of the North 1 Unit environmental tours during the recertification survey.

Inspectors wroteBased on observation and staff interviews, it was determined that the facility failed to maintain resident's right to a dignified existence as evidenced by clothing labeled with the resident's name visible from the outside. This was evident for 1 (Resident #84) of 2 residents investigated for dignity.

Inspectors wroteBased on observations and interviews, it was determined that the facility failed to provide housekeeping and maintenance services necessary to maintain a clean, sanitary, and safe environment. This was evident for 1 of 4 units (North 1) observed during environmental tours in the facility.

Inspectors wroteBased on interviews, review of complaint #2719958, and medical record review, it was determined that the facility failed to ensure a grievance resolution was implemented and maintained as evidenced by the facility failing to enforce a resolution preventing Registered Nurse (RN) #23 from providing care to Resident #12 after a grievance resolution mandated RN #23 would not provide care to the resident. This was found to be evident in 1 (Resident #12) of 1 resident reviewed for grievances.

Inspectors wroteBased on review of medical records and interviews with facility staff, it was determined that the facility failed to ensure a baseline care plan, including a current list of medications, was provided to the resident and/or resident representative (RP). This was evident for 1 (Resident #14) out of 50 residents reviewed during the facility's recertification survey.

Inspectors wroteBased on medical record review and resident and staff interviews it was determined the facility staff failed to ensure that dependent resident's personal hygiene needs were adequately met by offering and providing showers as scheduled. This was evident for 1 of 32 (#25) residents reviewed during the survey process.

Inspectors wroteBased on observations, record review, and staff interview, it was determined that the facility failed to follow a doctor's wound care order. This was evident for 1 (Resident #47) of 50 residents reviewed in the investigation phase of the survey.

Inspectors wroteBased on review of medical records and interviews with facility staff, it was determined that the facility failed to monitor and follow physician orders to obtain a resident's weight. This was evident for 1 (Resident #14) of 4 residents reviewed for nutrition during the facility's recertification survey.

Inspectors wroteBased on observations, medical record review, policy review, and staff interviews, it was determined that the facility failed to provide respiratory care consistent with professional standards and facility policy related to oxygen administration and nebulizer care. This is evident for 2 (Residents #3 and #47) of 6 residents reviewed for respiratory care during the recertification survey.

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure bed rails were used in accordance with facility policy and physician orders. This is evident for 2 (Residents #1 and #16) of 2 residents reviewed for bed rail use.

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure medications were stored in accordance with professional standards and manufacturer guidelines by failing to date an opened multidose medication vial. This is evident for 1 of 2 medication storage rooms reviewed.

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to assist a resident in obtaining routine and necessary dental services. This is evident for 1 (Resident #1) of 1 resident reviewed for dental services.

Inspectors wroteBased on observations and staff interviews it was determined that the facility failed to 1.) follow infection control policy and procedure by maintaining and storing the face mask and tubing for a resident's nebulizer in the manner that was consistent with the facility's policy and procedure, and 2.) ensure staff performed appropriate hand hygiene during medication administration and resident care to prevent the potential spread of infection This was evident for 1 out of 32 residents sampled and for 1 (Staff #34) of 3 staff observed during medication administration observations.

Inspectors wroteBased on medical record review and interview, it was determined the facility staff failed to notify a Resident's responsible party for a change in condition (Resident #3). This was evident for 1 of 10 residents reviewed during a complaint survey.

Inspectors wroteBased on medical record review and interview, it was determined that the facility staff failed to administer medications, treatments and supplements as ordered in a timely manner (Resident #3 and #6). This was evident for 2 of 10 residents reviewed during a complaint survey.

Inspectors wroteBased on a facility reported incidents, record review, and interviews, it was determined the facility failed to timely report an incident of abuse to the Office of Health Care Quality (OHCQ). This was evident for 6 (#63, #52, #84, #24, #71, #64) of 10 residents reviewed for abuse during the recertification/complaint survey.

Inspectors wroteBased on multiple complaint intakes, record review and staff interviews it was determined that the facility failed to 1) implement an intervention on a resident's care plan, 2) arrange for a resident with fractured arm to go for an orthopedic appointment, 3A/B) fail to timely administer prescribed medications to residents, 4) Promptly report a positive lab result to the physician and hold laxative for a resident with diarrhea. This was evident for 4 (#132, #140, #230 , #142) of 24 complaints reviewed during the recertification/complaint survey.

Inspectors wroteBased on clinical record reviews, Resident (R) and staff interviews, it was determined that the facility failed to have sufficient staff to meet the needs of the residents for 8 of 29 sampled residents (Residents #3, #110, #64, #14, #231, #116, #24, #51) and 15 complaints (MD00210759, MD00185809, MD00207746, MD00198916, MD00211341,MD00202774, MD00195025, MD00214748, MD00203187, MD00208031, MD00200792, MD00203145, MD00206608, MD00206731, MD00209653) that identified staffing issues and concerns reviewed during the recertification/complaint survey.

Inspectors wroteBased on observation and interview it was determined the facility failed to: 1) ensure secure storage of medications, and 2) ensure a nutritional supplement was not expired. This was evident for: 1) 3 out of 8 medication carts and 2) 1 out of 3 medication room refrigerators containing nutritional supplements during the facility's recertification/complaint survey.

Inspectors wroteBased on complaints, observations, record reviews and interviews with facility staff, it was determined that the facility failed to ensure that residents were served a meal according to a predetermined menu that incorporated the resident's preferences. This was evident for 4 residents (Residents #25, #59, #65, and #109) out of 14 residents reviewed during the facility's Medicare/Medicaid recertification/complaint survey.

Inspectors wroteBased on the surveyor's observation and interviews with staff members, it was determined that the facility failed to ensure that food in the storage and refrigerator was labeled and dated with preparation and expiration dates. This was observed during the initial tour of the kitchen during the facility's Medicare/Medicaid recertification/complaint survey.

Inspectors wroteBased on observation, resident interview, staff interview, and record review it was determined that the facility staff failed to ensure residents received two showers a week per resident preference. This was evident for 2 (Resident #59, and #66) out of the 66 residents in the survey sample.

Inspectors wroteBased on observation and interview it was determined the facility failed to ensure resident information was protected from public view. This was evident for one computer screen observed to have resident information exposed during the facility's recertification/complaint survey.

Inspectors wroteBased on record review and interviews, it was determined that the facility failed to exercise reasonable care for protection of resident's property from loss or theft. This was true for one resident (Resident #24) of 66 residents reviewed during the recertification/complaint survey. Findings Included: On 03/25/25 at 10:43 AM, in a interview with Resident #24, it was revealed that a total of $840 in cash was stored in the resident's wallets and kept at the bedside. The resident stated that the $840 was stolen (date not provided), the resident stated that $135 of the money was later returned in February 2025 but the resident was unsure what happened to the remaining balance. Resident #24 stated that he reported it to the unit manager (unable to provide a name) but no-one came back to say what happened after they completed their investigation. [...]

Inspectors wroteBased on resident and staff interviews and medical record reviews, it was determined that the facility failed to investigate an alleged abuse of a resident. This was evident for 1 (#64) of 66 residents reviewed during a recertification/complaint survey.

Inspectors wroteBased on record review and interview it was determined the facility failed to ensure the care plan of a resident was comprehensive and person centered. This was evident for one (Resident #26) out of two residents reviewed for limited range of motion during the facility's recertification/complaint survey.

Inspectors wroteBased on review of a complaint incident MD00198278, record review and staff interviews, it was determined that the facility failed to provide shower to a resident who was dependent. This was evident for 1 (Resident #140) of 24 complaints reviewed during the recertification/complaint survey.

Inspectors wroteBased on a complaint #MD00210759, record review and staff interviews, it was determined that the facility failed to accurately interpret a resident's MOLST form, evidenced by the initiation of Cardiopulmonary Resuscitation (CPR) on a resident with a documented Do Not Resuscitate order. This was evident for 1 (Resident #139) of 24 complaints reviewed during the recertification/complaint survey. The findings Include: Cardiopulmonary Resuscitation (CPR) is an emergency procedure that combines chest compressions and rescue breathing to restart a person's breathing or heartbeat when they've stopped. The Maryland Orders for Life Sustaining Treatment (MOLST) is a medical document that communicates a patient 's wishes or preferences regarding resuscitation when the patient has no pulse and/or is not breathing. [...]

Inspectors wroteBased on record review and interview it was determined the facility failed to ensure a complete medical order for a foley catheter was re-instituted for a resident upon their return from hospitalization, and failed to ensure that complete medical orders were verified and obtained for the foley catheter upon re-insertion of the catheter. This was evident for one (Resident #115) out of two residents reviewed for catheters during the facility's recertification/complaint survey.

Inspectors wroteBased on observation, medical record review, and interview, it was determined the facility failed to 1) properly date label oxygen tubing when changed, 2) follow physician's orders for the administration of oxygen, and 3) develop and implement a person-centered comprehensive care plan with resident centered goals for respiratory care to include oxygen therapy. This was evident for 1 (Resident #57) of 4 residents reviewed for respiratory care during a recertification/complaint survey.

Inspectors wroteBased on medical record reviews and interviews, it was determined the facility staff failed to ensure that a resident was given pain medication consistent with professional standards of practice, and failed to ensure pain mangement was effective. This was evident for 3 (#231,#33, #71) of 4 residents reviewed for pain management during a recertification/complaint survey.

Inspectors wroteBased on a complaint #MD00210759, record review and staff interviews, it was determined that the facility staff lacked proper knowledge required to interpret the MOLST form and on steps to follow in an emergency, as evidenced by performing Cardiopulmonary Resuscitation (CPR) on a resident with a documented Do Not Resuscitate order. This was evident for 1 (Resident #139) of 24 complaints reviewed during the recertification/complaint survey. The findings Include: Cardiopulmonary Resuscitation (CPR) is an emergency procedure that combines chest compressions and rescue breathing to restart a person's breathing or heartbeat when they've stopped. The Maryland Orders for Life Sustaining Treatment (MOLST) is a medical document that communicates a patient 's wishes or preferences regarding resuscitation when the patient has no pulse and/or is not breathing. [...]

Inspectors wroteBased on review of staff records and interview with facility staff, it was determined that the facility failed to ensure Geriatric Nursing Assistants (GNAs) received a performance review in 2023. This was evident for 1 (Staff #49) out of 3 GNAs randomly selected nursing staff records reviewed for annual training requirements during the recertification/complaint survey.

Inspectors wroteBased on record review and interviews, it was determined that the facility failed to ensure medication order parameters were followed and ensure a resident was free from unnecessary medication. This was evident for one (Resident #42) out of one resident reviewed for insulin during the facility's recertification/complaint survey.

Inspectors wroteBased on medical record review and interview it was determined the facility failed to ensure a prn (as needed) antipsychotic medication order was limited to 14 days and failed to ensure a resident was free from uneccessary medication. This was evident for one (Resident #116) out of eight residents reviewed for unnecessary medications during the facility's recertification/complaint survey.

Inspectors wroteBased on review of facility documentation and interview, it was determined the facility failed to have the required members participate on the facility's Quality Assessment and Assurance (QAA) committee meetings.