Autumn Lake Healthcare at Pikesville

Inspectors wroteBased on observation rounds and interviews, the facility failed to maintain an infection prevention and control program that properly identified the isolation necessary for residents, maintain infection prevention standards during resident care, and properly store and process linens to prevent the spread of infection to residents following accepted national standards. This was evident for 5 (#15, #110, #66, #45, and #89) of 55 residents and 1 of 2 of the laundry rooms observed during survey.

Inspectors wroteBased on interviews with residents and facility staff and record reviews, it was determined the facility failed to ensure that residents choices for discharge were properly facilitated by the facility staff. This was found to be evident for 2 (Resident #17 and #91) out of 4 residents reviewed for Choices during the facility's survey.

Inspectors wroteBased on record reviews and staff interviews, it was determined that the facility failed to provide Medicare beneficiaries with 1) Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage and 2) Notice of Medicare Non-Coverage. This was evident for 2 (Residents #50 and #72) out of 3 residents selected during the Beneficiary Protection Reviews.

Inspectors wroteBased on observations and interviews, it was determined that the facility failed to maintain a clean, in good repair and functional environment and building. This was evident during observations made on the 1 [NAME] Wing of the facility and resident room [ROOM NUMBER] during the survey.

Inspectors wroteBased on administrative record review and interviews with facility staff it was determined the facility staff failed to report allegations of abuse immediately. This was found to be evident for Resident #19 out of 5 intakes reviewed for abuse allegations during the facility's survey.

Inspectors wrote3) On 06/13/25 at 02:07 PM, Resident #97's record was reviewed. The record review revealed that Resident #97's Care Plan Conference Summary sheet, dated 04/28/25, indicated that the Activities Director #26, Unit Manager (Licensed Practical Nurse) #4, Dietician #27 and Social Work Director staff #8 were the only interdisciplinary team members who participated in updating Resident #97's care plan on 04/28/25. According to Resident #97's Care Plan Conference Summary sheet, dated 04/28/25, the attending physician as well as a registered nurse and a nurse aide, with responsibility to the resident, did not participate in updating Resident #97's care plan on 04/28/25. Also, the facility did not provide the surveyor with documentation indicating that the attending physician, registered nurse and nurse aide communicated their updates to Resident #97's care plan. [...]

Inspectors wroteBased on observation, record review, and interview it was determined that the facility failed to ensure that residents were free of significant medication errors as evidenced by facility staff failing to administer medications in accordance with professional standards. This was evident for 1 (#127) of 4 residents reviewed for medication administration.

Inspectors wroteBased on medical record review and interviews with facility staff it was determined the facility failed to ensure that medical records were maintained and accurate. This was found to be evident for 2 (Resident #17 and #91) out of 34 residents reviewed during the facility's survey.

Inspectors wroteBased on observations and interviews, it was determined that the facility failed to ensure that Resident #83 bed mattress and bed frame were compatible. This was evident for 1 resident bed out of 25 resident beds reviewed during the survey.

Inspectors wroteBased on observations and interviews, it was determined that the facility failed to maintain an effective pest control program so that the facility is free of pests. This was evident in 1 resident's bathroom out of 25 residents' bathrooms observed during the survey.

Inspectors wroteBased on review of medical records and facility investigation documentation, interviews and observations it was determined the facility failed to have an effective system in place to prevent residents with cognitive impairment from leaving the facility without appropriate supervision. More specifically, the facility failed to: 1.) Provide adequate supervision to prevent a resident with known wandering and exit seeking behaviors from exiting the facility unsupervised on 5/10/21, 2.) Ensure all staff check the functionality of the wander guard bracelets for residents currently in the facility with a bracelet in place that have exit seeking behavior; [...]

Inspectors wroteBased on facility documentation review and interview, the facility staff failed to provide evidence the facility had purchased a surety bond to assure the security of all the residents' personal funds deposited with the facility. This was evident during the investigation of facility tasks during an annual survey.

Inspectors wroteBased on clinical record review and staff interviews, it was determined that the facility failed to ensure the resident/responsible party was offered the opportunity to develop an advanced directive for 15 (#46, #76, #17, #87, #18, #28, #67, #1, #22, #49, #61, #95, #24, #75, #307) of 16 sampled residents for advanced directives.

Inspectors wroteBased on observation and interviews, it was determined that the facility failed to maintain a safe and clean environment as evidenced by 1) sagging ceiling tiles in resident rooms, 2) stained ceiling tiles, 3) walls in resident rooms that were in disrepair, 4) soiled linen and trash/debris on the floor and, 5) a rusted tube feeding pole. This was found to be evident throughout both floors of the facility.

Inspectors wroteBased on record reviews, observation, and staff interview, it was determined that the facility failed to develop and implement comprehensive person centered care that were resident specific with measurable objectives and goals. This was evident for 17 (#46, #58, #80, #208, #84, #251, #17, #76, #53, #401, #307, #95, #89, #311, #1, #49, #152 ) of 38 residents reviewed during the annual survey, however affected all residents as only samples were provided in this citation.

Inspectors wroteBased on a review of resident medical records and interviews with facility staff, it was determined that the facility failed to 1) hold care plan meetings of the interdisciplinary team for residents at the time of the quarterly revision of their care plan and 2) review and revise resident care plans after each assessment or as resident care needs became apparent or changed over time. This was evident for 2 (#67, #401) of 4 residents reviewed for care plan meetings and 7 (#46, #84, #1, #27, 49, 152, #89) of 38 residents reviewed during the annual survey, however affected all residents on units that did not have a unit manager.

Inspectors wroteBased on review of employee files and staff interview it was determined that the facility staff failed to put a system in place to ensure that Geriatric Nursing Assistants (GNA) are evaluated annually and provided appropriate re-education based on the outcome of these evaluations. This was found to be true for 5 of 5 GNA employees (Staff #68, #69, #70, #71, #72) reviewed for annual evaluations. This deficient practice has the potential to affect all the residents in the facility.

Inspectors wroteBased on observation and interview, it was determined the facility failed to consistently maintain a sanitary environment in the kitchen. This was evident during the initial tour of the kitchen and during 2 subsequent visits.

Inspectors wroteBased on review of pertinent documentation, observation and interview it was determined that the facility administration failed to 1) ensure that all staff, including agency staff, were educated on elopement prevention, 2) update the facility assessment to address elopement and COVID-19, 3) correct deficiencies from a previous complaint survey and 4) obtain and utilize resources necessary to provide for the needs of the residents. This was evident from 7/21/22 to 8/11/22 (16 days) of the annual survey which resulted in 52 Federal citations and identification of an Immediate Jeopardy.

Inspectors wroteBased on review of facility records and interview with staff, it was determined the facility failed to conduct and document an accurate facility-wide assessment that was up to date. This was evident during review of the sufficient and competent nurse staffing task of the annual survey. This had the potential to affect all residents within the facility.

Inspectors wroteBased on interviews, reviews of facility and resident records, and current survey findings it was determined that the facility failed to have an effective Quality Assessment Performance Improvement (QAPI) plan to ensure care and services are maintained at acceptable levels of performance and continually improved. This had the potential to affect all residents within the facility.

Inspectors wroteBased on interviews, reviews of facility and resident records, current survey findings and the facility's prior complaint surveys it was determined that the facility failed to have an effective Quality Assessment Performance Improvement (QAPI) program to develop and implement effective plans of action to correct identified quality deficiencies. This failure resulted in 4 repeat deficiencies found during the current annual survey. This was evident during the survey process and review of the Quality Assurance Program.

Inspectors wroteBased on observation and staff interviews it was determined that the facility failed to implement an effective infection control program and facility staff failed to follow infection control practices and guidelines to prevent the development and transmission of disease by 1) failing to keep contact/isolation room door closed on the 1st East unit. This was evident for 1 (Resident #401) of 15 residents' rooms observed, 2) failing to provide education and convey updates to staff on COVID-19. This was evidenced by 49 out of 115 staff who did not receive COVID-19 education in November 2021, 3) failing to change oxygen tubing and label when changed. This was evidenced by 1 (#76) of 3 residents reviewed for respiratory care and 4) failed to follow infection control practices in the laundry room and kitchen. [...]

Inspectors wroteBased on observation and staff interview it was determined the facility failed to keep the second walk-in freezer and dishwasher in the kitchen in safe operating condition. This was evident during the initial tour of the kitchen and during 2 subsequent visits.

Inspectors wroteBased on observation and staff interviews, it was determined that the facility staff failed to provide a safe, functional, sanitary, and comfortable environment for residents, evidenced by 1) ongoing renovation construction in the facility building since October 2019, 2) uncapped sides of handrails at the 2-East wing, 3) broken wall behind the water purifier on the second floor near between 2-West nursing station and medication storage room, and 4) approximately 1.5 cm x 0.5 cm size, rusty, flat metal piece with one side that was sharpened and the other side was flat found on the hallway on the 2nd floor of the facility. This deficient practice has the potential to affect all residents, staff, and visitors in the facility.

Inspectors wroteBased on staff interview, observation, and documentation review it was determined the facility failed to ensure an adequate amount of potable emergency water was always available. This was evident during a tour of the kitchen during the annual survey. This had the potential to affect all residents.

Inspectors wroteBased on review of employee file documentation and interview it was determined that the facility failed to have a process to ensure all Geriatric Nursing Assistants (GNAs) have no less than 12 hours of education per year and the education included annual dementia management training and resident abuse prevention training. This is evident for 5 of 5 GNA employment files reviewed and 1 (staff #69) of 5 GNAs that did not have abuse prevention training. This is evident for 5 (#68, #69, #70, #71, #72) of 5 GNA employment files reviewed and 1 (staff #69) of 5 GNAs that did not have abuse prevention training.

Inspectors wroteBased on record review and staff interview it was determined the facility staff 1) failed to notify the physician that a medication for an elevated potassium level was unavailable and 2) failed to have a system in place to notify the physician when residents' weight loss was identified. This was evident for 1 (Resident #251) of 1 resident reviewed for an unexpected death and 3 (Resident #73, #67, #402) of 7 residents reviewed for weight loss.

Inspectors wroteBased on interview and medical record review it was determined the facility failed to notify the resident/resident representative in writing of a transfer/discharge of a resident or with the reason for the transfer. This was evident for 3 (#57, #61, #83) of 5 residents reviewed for hospitalization during the annual survey.

Inspectors wroteBased on interview and medical record review it was determined the facility failed to notify the resident/resident representative in writing of the bed hold policy upon transfer of a resident to an acute care facility. This was evident for 3 ( #57, #61, #83) of 5 residents reviewed for hospitalization during the annual survey.

Inspectors wroteBased on medical record review and staff interview it was determined the facility staff failed to conduct a complete assessment by failing to assess a resident's cognition and mood on quarterly MDS assessments. This was evident for 5 (#4, #7, #98, #47 #28) of 38 residents reviewed during the annual survey.

Inspectors wroteBased on medical record review and staff interview, it was determined the facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded. This was evident for 10 (#53, #87, #57, #58, #80, #208, #251, #28, #67, #311,) of 38 residents reviewed during the annual survey.

Inspectors wroteBased on medical record review and staff interview, it was determined the facility failed to provide the resident or resident representative with a summary of their baseline care plan on admission and failed to accurately assess the resident. This was evident for 6 (#58, #208, #251, #416, #307, #89) of 38 residents reviewed during the annual survey.

Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to ensure that residents with limited range of motion received the appropriate treatment and services to prevent further decline in range of motion. This was evident for 3 (#17, #53, #55) of 6 residents reviewed for positioning and mobility during the annual survey.

Inspectors wroteBased on medical record review and staff interview it was determined the physician progress notes were not in the resident medical records the day the resident was seen. This was evident for 5 (#46, #80, #55, #67, #65,) of 38 residents reviewed during the annual survey.

Inspectors wroteBased on review of facility records and interview with staff, it was determined the facility failed 1) ensure that nurse aides are able to demonstrate competency in skills and techniques necessary to care for residents' needs and 2) failed to ensure all nursing staff had the specific competencies and skill sets necessary to care for residents with a Nephrostomy tube. This was evident for 2 (Staff #71 and #72) of 5 randomly selected GNAs reviewed for competency review and 2 (# 89 and #83) out of 2 residents with Nephrostomy tubes reviewed.

Inspectors wroteBased on medical record review and staff interview it was determined the facility failed to keep a resident's drug regimen free from unnecessary drugs by failing to 1) monitor the blood pressure and heart rate prior to administering a blood pressure medication and 2) follow physician ordered blood pressure parameters for administering Metoprolol, a blood pressure medication. This was evident for 1 (#80) of 7 residents reviewed for unnecessary drugs during the annual survey.

Inspectors wroteBased on observation and staff interview it was determined facility staff 1) failed to keep medication carts locked when unattended and 2) failed to date medication and biologicals when opened, and failed to discard insulin, food supplements, inhalers, and oral medications when expired. This was evident on 2 of 4 nursing units observed during the annual survey.

Inspectors wroteBased on observation and staff interview it was determined that the facility failed to have quality laboratory supplies for resident diagnostic testing in 1 of 2 medication rooms observed during the annual survey.

Inspectors wroteBased on medical record review and interview, it was determined the facility staff failed to maintain a medical record in the most accurate form. This was evident for 10 (#251, #84, #76, #53, #18, #28, #61, #401, #73, #24 ) of 38 residents reviewed in the investigative stage of the annual survey.

Inspectors wroteBased on observation, staff interviews, complaints from anonymous staff, and facility documentation review, it was determined that facility staff failed to maintain an effective pest control program, so the facility was free of pests. This practice had the potential to affect all residents, staff, and visitors.

Inspectors wroteBased on surveyor observation, interview, and record review it was determined that the facility staff failed to: 1) protect and value resident's private space by failing to knock and request permission before entering a resident's room, and 2) ensure a urine collection bag had a privacy cover and was out of sight of the public. This was evident but not limited to 1 of 7 residents (Resident #57) reviewed on the 1 [NAME] Unit and 1 (#83) of 4 residents reviewed for urinary catheters during the annual survey.

Inspectors wroteBased on a review of complaint MD00177146, medical record review, observations, and interviews with the resident, and facility staff, it was determined that the facility 1) failed to optimize the living environment for a resident with a request to add weather-stripping to the bottom of the resident's bedroom door and 2) failed to ensure access to the nurse call bell for residents residing in the facility. This was evident for 1 (complaint MD00177146) of 4 complaints reviewed for Resident #50 and 1 (Resident #53) of 32 residents reviewed during the initial stage of the annual survey.

Inspectors wroteBased on policy and facility documentation review and interviews it was determined that the facility failed to implement their policy regarding reporting allegations of abuse, neglect, and exploitation of residents and misappropriation of resident property. This was evident for 2 (#58, #412) of 8 residents reviewed for abuse during the annual survey.

Inspectors wroteBased on medical record review and staff interview, it was determined that the facility failed to orient, prepare, and document a resident's preparation for a transfer to the hospital. This was identified for 2 (#57, #61) of 5 residents reviewed for hospitalization during an annual certification survey.

Inspectors wroteBased on medical record review and staff interview it was determined the facility staff failed to conduct an accurate, comprehensive assessment by failing to assess a resident's mood and cognitive status on comprehensive and quarterly MDS (Minimum Data Set) assessments. This was evident for 3 (#27, #46, #28) of 38 residents reviewed during the annual survey.

Inspectors wroteBased on observation, medical record review, and staff interview, it was determined the facility failed to follow a physician's ordered treatment. This was evident for 1 (Resident#61) of 1 resident reviewed for non-pressure skin condition.

Inspectors wroteBased on observation, medical record review, and interview, it was determined the facility 1) failed to properly date label oxygen tubing when changed, 2) failed to follow physician's orders for the administration of oxygen, and 3) failed to develop and implement a person centered comprehensive care plan with resident centered goals for respiratory care to include oxygen therapy. This was evident for 2 (#307 and #76) of 3 residents reviewed for respiratory care during the annual survey.

Inspectors wroteBased on medical record review and staff interview it was determined the facility pharmacist failed to identify and report irregularities in the resident's drug regimen to the physician, facility's medical director and the director of nursing. This was evident for 1 (#80) of 7 residents reviewed for unnecessary medications.

Inspectors wroteBased on medical record review and staff interviews, it was determined that facility staff failed to ensure residents were free from significant medication errors as evidenced by failing to follow a physician's order related to holding blood pressure medications if outside of physician ordered parameters. This was evident for 1 (#251) of 5 residents reviewed for medication pass observation and 1 (#151) of 2 residents reviewed for death during the annual survey.

Inspectors wroteBased on medical record review and interview it was determined that facility staff failed to provide timely dental care. This was evident for 1 (#28) of 3 residents reviewed for dental during the annual survey.

Inspectors wroteBased on observation, record review, and interview it was determined the facility failed to provide rehabilitation services following the recommendation from an orthopedic physician consult. This was evident for 1 (#55) of 2 residents reviewed for rehabilitation.

Inspectors wroteBased on record review and staff interview, it was determined that the facility staff failed to document that resident and/or their Responsible Parties (RPs) were provided education on Pneumococcal vaccines before requesting consent. This was evident for 1 (Resident #401) of 5 residents reviewed for Immunizations during the survey.

Inspectors wroteBased on staff interviews and record review, it was determined that the facility failed to properly prevent the transmission of COVID-19 by failing to conduct staff testing twice a week during the time the facility was in a COVID-19 outbreak. This was evident for 1 (Staff #41) of 5 randomly selected staff reviewed for COVID-19 testing during the survey.

Inspectors wroteBased on medical record review and staff interview, it was determined the facility failed to document providing education regarding the benefits, risks, and potential side effects of receiving the COVID-19 vaccine to residents and staff. This was evident for 1 (Resident #401) of 5 residents and 2 (staff #10 and #20) of 4 facility staff members reviewed for COVID-19 vaccinations during the survey.

Inspectors wroteBased on observations and interviews, it was determined the facility failed to ensure that residents had access to alert staff for assistance through the facility's call bell system. This was evident in 1 (resident #61) of 32 resident call bells activated during this survey.

Inspectors wroteBased on request for historical staffing sheets the facility failed to maintain the posted daily staffing sheets for resident and public access. 3 of 3 dates for staffing sheets requested were not provided.

Inspectors wroteBased on medical record review and family and staff interview it was determined the facility failed to accommodate Resident #21 by leaving the television on a channel where Russian was the primary language spoken. This was evident for 1 resident investigated for language concerns during the survey.

Inspectors wroteBased on observation, medical records review, and family and staff interview it was determined the facility failed to ensure that Resident #21 was shaved daily. This was evident for 1 resident reviewed for activities of daily living during the survey.

Inspectors wroteBased on observation and staff interviews it was determined that the facility staff failed to ensure that food was stored and prepared in sanitary manner. This practice has a potential of effecting all residents in facility.

Inspectors wroteBased on observation and staff interview it was determined the facility failed to ensure that equipment used for personal hygiene was stored appropriately in a room shared by Residents #44 and #55. This was evident for 2 of 32 residents reviewed during the survey.