Autumn Lake Healthcare at Silver Spring

Inspectors wroteBased on record review and interview, it was determined the facility failed to report allegations of abuse to the State Agency (SA) within the required timeframe. This was evident for 1 (#2) of 1 resident reviewed for an abuse allegation.

Inspectors wroteBased on record review and interview, it was determined that the facility failed to ensure that a staff member was removed from the resident care area following an allegation of abuse to ensure the safety of all residents until an investigation was completed. This was evident for 1 (#2) of 1 resident reviewed for abuse allegation.

Inspectors wroteBased on record review and interview, it was determined that the social services department failed to ensure that a resident received medically related social services. This was evident for 1 (#1) of 1 resident reviewed for discharge.

Inspectors wroteBased on record review and interview, it was determined that the facility failed to provide their residents with rehabilitation services based on their plan of care as required. This was evident for 1 (#1) of 1 resident reviewed for rehabilitation services.

Inspectors wroteBased on observation and interview, it was determined facility dietary staff failed to maintain proper infection control procedures by using serving warming plates and cloches that had been wet nesting and were still wet with standing water when the residents' plates of food were placed in them. Wet nesting is a sanitation hazard occurring when recently washed, wet, or damp items (like plates, pots, or bowls) are stacked together. This practice restricts airflow, creating a dark, moist environment that promotes rapid bacterial growth and mold. During the survey observation of the lunch plating, it was observed that the warming plates and cloches that were being used were very wet with the warming plates having standing water in them. This was observed when the warming plates were being set on the warming charger and the water in the them began to boil with obvious bubbles. [...]

Inspectors wroteBased on review of employee files and interviews with facility staff, it was determined that the facility failed to conduct required performance reviews of Geriatric Nursing Assistants (GNAs) at least once every 12 months. This was evident for 4 (GNA #17, #19, #20, #5) out of 5 GNAs' employee files reviewed during the Sufficient and Competent Nursing Staffing portion of the facility's recertification survey.

Inspectors wroteBased on observations, interviews, and record review, it was determined that the facility failed to implement appropriate infection control practices as evidenced by 1) failing to ensure oxygen tubing and humidification bottles were dated to indicate timely replacement, 2) not stocking enough Personal Protective Equipment (PPE) outside resident rooms, and 3) using appropriate infection control practice during urinary catheter maintenance. This was found to be evident for 9 (Residents #3, #9, #22, #116, #157, #158, #23, #30, and #155) of 47 residents investigated during the recertification survey.

Inspectors wroteBased on medical record review and facility staff interview it was determined that the facility failed to ensure that Resident #33's personal belongings were secured. This was evident for 1 out of 1 residents observed. During a complaint investigation it was discovered that the facility could not account for some of Resident #33's belonging. The complaint alleged that the resident was missing a phone charger, 3 white tee shirts, 3 ball caps, and a pair of sweatpants. The medical record and the paper chart were reviewed for an inventory sheet for the resident, and none was found. A copy of the facility's policy for Resident's Personal Belongings was requested and acquired. This policy clearly stated that All resident personal items will be inventoried at the time of admission and documentation shall be retained in the medical record. [...]

Inspectors wroteBased on review of the medical record and pertinent documentation and interviews with facility staff, it was determined that the facility failed to transmit MDS assessments within 14 days of completion of the assessment. This was evident for 1 (Resident #53) of 1 residents reviewed for resident assessment.

Inspectors wroteBased on medical record review, and facility staff interview, it was determined that the facility staff failed to develop and initiate comprehensive person-centered care plans for residents residing in the facility. This was evident for 2 (#33, #47) of 33 residents reviewed during the recertification survey. A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care. On 03/26/2026 at 11:25 AM, during a review of the medical record for Resident #47, it was determined that the resident's dental issues were not addressed in their care plan. The contract dental service had been seeing the resident, had identified the resident's dental issues and were working to resolve them by replacing the resident's dentures. [...]

Inspectors wroteBased on observations, medical record review, and interviews, it was determined that the facility failed to follow provider orders. This was found to be evident in 1 (Resident #3) of 47 residents reviewed during the recertification survey.

Inspectors wroteBased on record reviews and interviews with facility staff, it was determined that the facility failed to ensure monthly Medication Regimen Reviews were completed by a provider and to respond to and address recommendations made by consulting pharmacists in a timely manner. This was evident for 1 (Resident #29) of 5 residents reviewed for unnecessary medications during the facility's recertification survey.

Inspectors wroteBased on observations and interviews of facility staff it was determined the facility failed to ensure an effective pest control program as flying gnats were observed throughout the first floor of the building. This was found to be evident during the survey.

Inspectors wroteBased on medical record review and interview with facility staff, it was determined that that facility failed to ensure that care plan meetings were scheduled quarterly and included the resident and representative. This was evident during the review of a complaint and review of 1 of 3 resident (1).

Inspectors wroteBased on random observations of the Arcadia unit, it was determined that the facility failed to ensure the doors exiting the unit were in good repair and created a safe and comfortable environment for residents.

Inspectors wroteBased on observation, interview, job description review, document review and policy review, the facility failed to employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition department having the potential to affect all residents. The facility failed to ensure adequate oversight of dietary/nutrition services from the Registered Dietitian (RD), who worked part time, had not been to the facility since July of 2024. In addition, the facility failed to ensure the Food Service Director (FSD) was qualified. This resulted in failures to provide palatable food, provide food alternates/choices, provide snacks, serve meals without extended timeframes between dinner and breakfast, and provide nutritional interventions to prevent unplanned weight loss.

Inspectors wroteBased on observations, interview, document review, and policy review, the facility failed to ensure that the kitchen was maintained in a sanitary manner to prevent the potential spread of foodborne illness to 126 out of 129 residents (three residents received nutrition via feeding tubes). Specifically, dietary staff did not adhere to hand hygiene/glove use requirements for ready to eat food and the dishwasher was not operating in accordance with manufacturer's specifications.

Inspectors wroteBased on observations, interview, and policy review, the facility failed to maintain the outdoor garbage area in a sanitary manner for three of three days of the survey creating the potential for the harborage of pests which could affect all 129 residents.

Inspectors wroteBased on observations, interview, record review, and policy review, the facility failed to ensure two of 37 sampled residents (Residents (R) R184 and R19) received nutritional interventions to address significant weight loss. Specifically, these two residents were not served enough food; did not receive prescribed nutritional interventions; were not offered alternates when they did not eat, when they experienced significant unplanned weight losses. Staff documented R19 and R184 eating meals and consuming supplements that they did not eat or consume.

Inspectors wroteBased on observations, interview, record review, document review and policy review, the facility failed to ensure the food was palatable for 13 out of 37 sampled residents (Resident (R)88, R84, R46, R99, R123, R338, R21, R85, R60, R101, R7, R121, and R18). The food was not appetizing, prepared according to standards/recipes, or hot when residents received their meals. This created the potential for dissatisfaction and weight loss.

Inspectors wroteBased on observations, interview, record review and policy review, the facility failed to ensure that resident's preferences/dislikes were assessed and followed; that alternatives were available; and that alternatives were offered to residents who did not eat what was served for 10 of 37 sampled residents (Residents (R)85, R46, R88, R121, R7, R95, R58, R60, R94 and R184). This created the potential for weight loss and resident dissatisfaction.

Inspectors wroteBased on observations, interviews, record review, document review and policy review, the facility failed to ensure that nutritional needs were met for four of 37 residents (Resident (R)46, R84, R88 and R18) frequency of meals and receiving snacks at bedtime. These failures could result in potential health issues due to deficiencies in vitamins, minerals, protein, and calories when nutritional body requirement needs are not being met.

Inspectors wroteBased on observation, interview, and policy review, the facility failed to ensure one of four (Licensed Practical Nurse (LPN) 3) followed infection control practices when dispensing medication in that LPN3 dropped a pill on top of the medication cart and then picked up the pill and placed it in the medication up for one of five residents (R) 100) administered medications.

Inspectors wroteBased on medical record review and interview, it was determined the facility staff failed to notify the resident's responsible party (RP) and physician timely when a resident had a change of condition (Resident #21). This was evident for 1 of 28 residents reviewed during a complaint survey.

Inspectors wroteBased on review of facility records and interview, it was determined that the facility failed to conduct a thorough investigation. This was found to be evident for 1 out of 3 facility reported incidents.

Inspectors wroteBased on medical record review and interview, the facility staff failed to provide treatment/services to prevent/heal pressures ulcers (Resident #4). This is evident for 1 of 28 residents reviewed during a complaint survey.

Inspectors wroteBased on medical record review and interview, the facility nursing staff failed to inform facility nursing management that a resident (#17) with a diagnosis of Schizophrenia became increasingly combative with staff after a reduction in a mood regulating medication. This is evident in 1 of 28 residents reviewed during a complaint survey.

Inspectors wroteBased on review of resident medical records and interview with facility staff, it was determined that the facility failed to ensure each resident's drug regimen was free from unnecessary drugs (resident #14). This was evident for 1 of 28 residents reviewed during a complaint survey.

Inspectors wroteBased on observation, medical record review, and staff interview, it was determined the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards (Resident #4) This was evident for 1 of 28 residents reviewed during a complaint survey.

Inspectors wroteBased on record review, interview with facility staff, Hospice case manager, and surveyor observation, it was determined that the facility failed to develop a comprehensive person-centered care plan for each resident. This finding was evident for 3 of 26 residents (#9, 70, & 292) selected for review during the survey.

Inspectors wroteBased on surveyor observations, review of residents' clinical records, and interviews with facility staff and residents and resident's representatives, it was determined that the facility failed to ensure residents' rights to participate in activities inside and outside the facility. This finding was evident for 2 of 3 (#34 & 106) residents selected for review of transmission-based precautions.

Inspectors wroteBased on surveyor review of the clinical record and interview with facility staff, it was determined that the facility staff failed to ensure nursing standards of practice in obtaining physician/nurse practitioner clarification for medical orders. This finding was evident for 2 of 32 residents selected for review during the survey. (#96, #133)

Inspectors wroteBased on surveyor observations, clinical record review, interviews with the Ombudsman, resident representatives and facility staff, it was determined that the facility failed to maintain grooming and personal hygiene for a resident who was unable to carry out activities of daily living. This finding was evident for 1 of 2 (#12) residents reviewed for dignity during the survey.

Inspectors wroteBased on surveyor observations, clinical record reviews, and interviews with facility staff, it was determined that the facility failed to provide care in accordance with professional standards of practice as evidenced by not following a physician's order. This finding was evident for 1 of 26 residents (#141) reviewed for this survey.

Inspectors wroteBased on surveyor observation and interview with facility staff, it was determined that the facility failed to appropriately store medications and failed to appropriately dispose of expired medications. This finding was evident for 2 of 3 nursing stations (1st and 2nd floor).

Inspectors wroteBased on surveyor review of the clinical and administrative records and interview with the facility staff, it was determined that the facility staff failed to provide the SNFABN (Skilled Nursing Facility Advanced Beneficiary Notice) notice to 1 of 3 (#56) residents selected during the Beneficiary Protection Notification reviews during this survey.

Inspectors wroteBased on surveyor review of a closed clinical record and interview with facility staff, it was determined that the facility failed to ensure accurate documentation on the MDS (Minimum Data Set) for resident #143. This finding was evident for 1 of 3 residents selected for the Closed Record Sample review.

Inspectors wroteBased on surveyor review of the clinical record and interview with facility staff, it was determined that the facility staff failed to ensure accurate documentation in the clinical record for resident #133. This finding was evident for 1 of 32 residents selected for review during the survey.