Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Autumn Lake Healthcare At Oak Manor during CMS and state inspections, most recent first.
Failure to Respect Resident Privacy and Dignity: A PT entered a resident’s room and opened the bathroom door without consent while the resident was unclothed from the waist up. The resident, who was cognitively intact and receiving rehab, reported that the PT ignored being told someone was inside and remained at the doorway while the resident tried to cover up. The Administrator confirmed the PT failed to treat the resident with respect and dignity.
Failure to Notify Provider of Elevated Heart Rate: A resident with CVA, HTN, atherosclerotic heart disease, and inappropriate sinus tachycardia had a documented HR of 122 bpm after prior readings were consistently lower, but the record did not show that the MD or NP was notified. The unit manager and NP both stated they would expect notification of the abnormal HR and further assessment of the resident's status.
Incomplete documentation of elevated heart rate and medication administration. A resident with cerebral infarction, HTN, atherosclerotic heart disease, and inappropriate sinus tachycardia had a documented HR of 122 bpm, but the record did not show a reassessment or any documentation of symptoms later that day. The MAR also showed evening meds as not given because the resident had died, while an RN stated the meds were actually given earlier and the DON confirmed the record did not match the nurse’s statement.
A facility failed to notify multiple residents receiving Medicaid benefits when their personal account balances exceeded the SSI resource limit threshold. Surveyors found 8 residents with balances above $2,500 and reviewed notification letters signed by staff and, in several cases, by residents with documented cognitive or decision-making impairment, including residents with physician certifications of incapacity, a court-appointed guardian, and a spouse who signed despite not being the documented POA.
The facility inaccurately coded multiple residents’ MDS assessments. Errors included a resident coded for restraints despite staff stating no fall mats or restraints were ever used, a resident coded as not receiving antipsychotic medication despite daily Seroquel administration, a resident coded with English as the preferred language despite speaking primarily Vietnamese, and a resident coded as not having an MDRO despite orders for EBP and documentation of C. auris positivity.
The facility failed to educate and offer annual COVID-19 vaccination to eligible residents. Record review showed several residents had prior COVID-19 immunizations, but there was no documentation that they were educated, offered the vaccine, or that the vaccine was refused during the review period. The DON confirmed the facility offers immunizations annually and acknowledged the residents should have been offered COVID-19 vaccination.
Failure to Support Communication for a Resident with LEP: A resident whose preferred language was Vietnamese did not receive direct communication support from staff. The resident and family reported that staff usually relied on family members to translate, and a GNA stated that staff used gestures or items the resident brought to express needs, with no communication board or language line observed. The DON stated she did not believe staff used a communication board with the resident.
Delayed Reporting of Abuse Allegation: A resident alleged that a staff member hit them, but the allegation was not reported right away. Staff became aware of the incident first, the NHA learned of it later, and the initial report was submitted after that. The facility policy states that any allegation of abuse must be reported to the Administrator immediately.
A resident with severe cognitive impairment and a certificate of incapacity was transferred to the hospital after a change in condition with SpO2 of 76% and aspiration pneumonia. The facility produced a hospital transfer and bed hold notice signed by the resident, but staff interviews confirmed the resident could not understand or sign the documents, and the DON acknowledged the discrepancy.
Failure to refer two residents with serious mental disorders for Level II PASARR review. One resident had schizoaffective disorder, schizophrenia coded on the MDS, and routine olanzapine use; another had bipolar disorder, bipolar disorder coded on the MDS, and olanzapine via PEG. In both cases, the hospital PASARRs omitted the psychiatric dx and antipsychotic use and were marked auto approved with no Level II required, and staff stated updated PASARRs were not available.
A resident’s care plan was not revised to match a physician order for EBP for MDRO. The record still directed Contact Precautions for Candida auris and Candida albicans, even though the resident had no indwelling catheters and had covered foot wounds, and the DON provided an email stating the resident could be on EBP because C. auris is a CDC-targeted MDRO.
The facility failed to maintain professional standards of practice related to oxygen orders for a resident who was observed receiving oxygen therapy, but the record review did not show an active oxygen order. The concern was brought to the DON, who indicated understanding.
Call Bell Not Kept Within Reach: A resident’s call bell was repeatedly observed on the floor and out of reach during several observations. A GNA stated the call bell should be within reach at all times and noted the resident did not have a clip on the cord, making it difficult to keep within reach. The DON stated call bells are expected to be within reach and clipped.
A resident with COPD had an active order for oxygen via nasal cannula at 2 L/min every shift, but surveyors observed the resident receiving 3L on two occasions. The care plan did not include oxygen therapy interventions, and the resident was later found connected to an empty O2 tank while seated in a wheelchair. Staff were unsure of the ordered flow rate, and the administrator acknowledged the resident should not have been connected to an empty tank.
The facility failed to ensure a resident’s Clonazepam was available when ordered after admission, and the MAR showed the medication was not given for several days while staff documented they were waiting for it from the pharmacy. The facility also failed to administer another resident’s Timolol eye drops on time, with the medication given more than an hour late 22 times by multiple nurses. The DON confirmed both the delay in obtaining the controlled medication and the late medication administrations.
A resident did not receive PT as ordered. The resident said PT was supposed to occur 3 times per week but rarely happened, and record review showed only a few PT sessions over 2 months despite an active order for skilled PT 3-5 times per week. The PT Director said the facility sometimes provided only 1 or 2 sessions weekly for the resident, and the Regional PT Director said the order should have included PRN because the resident had plateaued but could not be discharged from PT.
A facility failed to ensure EBP were followed during PICC line care for a resident with an order for EBP at all times. An agency RN administered IV medication through the PICC line wearing gloves only, despite a yellow door sign indicating EBP and the facility’s requirement for gowns and gloves; the nurse stated she was not aware of the precautions and had not yet received training.
A cognitively impaired resident with Alzheimer's and a high risk for wandering was able to exit the facility unsupervised due to a low-volume door alarm that was not clearly audible to staff. The resident was discovered missing after staff responded to a faint alarm and found an exit door open and unlocked. Despite a care plan and wander guard in place, the resident was not located until the following day, after an extensive search involving staff and law enforcement.
A resident experienced a significant, unaddressed weight loss over one month, with no documentation by the physician or dietitian of interventions or follow-up, despite care plan requirements to notify and act on such changes.
A resident requiring feeding assistance was left without a meal and unattended for an extended period during dinner, despite multiple staff being present in the dining room. The resident remained without food until another staff member, after serving trays elsewhere, began to assist. Staff interviews confirmed low staffing and a lack of timely feeding support for residents needing assistance.
Surveyors observed that two clean utility rooms contained dirty intravenous poles and an oxygen concentrator, all with visible solid matter and lacking labels to indicate cleanliness. Staff confirmed these items were improperly placed in clean areas and should have been in soiled utility rooms until cleaned and labeled.
A physician order for a GI consultation for a resident with poor oral intake and weight loss was not completed or scheduled as required. The DON confirmed the consultation should have been arranged, but no evidence was found in the medical record that this had occurred.
A resident with diverticulitis experienced significant, ongoing weight loss and difficulty with food intake, yet staff failed to implement new interventions or notify the physician despite multiple system alerts and an existing care plan identifying the risk. Interviews confirmed that required monitoring and follow-up actions were not carried out.
Two residents with significant weight loss did not have required physician documentation of their medical history and treatment plans. In both cases, despite ongoing monitoring and interventions by dietary staff, there was a lack of physician or nurse practitioner notes summarizing the treatment approach or relevant diagnoses in the medical records.
Surveyors found that three hot food items served in the dining area were below the required temperature of 135°F, with potatoes at 119.8°F, spinach at 109.2°F, and veal at 123.1°F. These findings were confirmed by dietary management staff.
Surveyors identified several breaches in food service sanitation, including unlabeled repoured applesauce containers on a dirty utility table, soiled linens stored in the dry storage room, food and liquid spills on the kitchen floor, a red substance spilled on refrigerator shelves, and an unkempt dish rinsing area with food particles left in the strainer. These conditions reflect a failure to follow professional standards for food safety and cleanliness.
The facility failed to document and address significant weight loss in two residents, including lack of evidence that interventions were implemented, physicians were notified, or interdisciplinary teams were informed. Medical records did not reflect required actions or monitoring, and staff interviews confirmed that documentation and notifications were not completed as per protocol.
During a dinner service, a staff member assisted a resident with feeding after picking up utensils from the floor for another resident, but failed to sanitize her hands before resuming care. The staff member believed using a napkin was sufficient and did not perform proper hand hygiene.
Surveyors found that several residents were not consistently served meals according to their food preferences, as menu slips focused on dietary restrictions rather than individual choices. Staff, including dietary aides and nursing personnel, confirmed that they did not routinely verify or accommodate resident preferences during meal service, and the dietary manager acknowledged the absence of a system to ensure preferences were honored.
A resident left the facility without a physician's order for a therapeutic leave of absence, due to a lack of supervision. The resident, assessed as low risk for elopement, left to attend a church service in the community after being unaware of its cancellation within the facility. The resident was found by police and returned without injuries. The facility's policy requires a physician's order for such absences, which was not obtained.
Failure to Respect Resident Privacy and Dignity
Penalty
Summary
The facility failed to treat a cognitively intact resident with dignity and respect when a physical therapist entered the resident’s room and bathroom area without consent while the resident was unclothed from the waist up. The resident, who had a BIMS score of 15 out of 15 and was admitted for rehabilitation after a hospitalization in April 2026, stated he/she was in the bathroom with the door closed when the therapist knocked, opened the door anyway after being told someone was inside, and remained at the doorway for about 2 to 3 minutes while the resident tried to cover up. The resident reported the incident to staff and completed a grievance. The physical therapist stated he had gone to the wrong floor, knocked twice, entered the room when no one answered, and then noticed the bathroom door was closed. He stated he knocked, heard the resident say he/she was in the bathroom, and then cracked the door open because he was worried about the resident’s safety. He stated he only opened the door a few inches and then closed it and apologized through the closed door. The Administrator confirmed that the physical therapist failed to treat the resident with respect and dignity by opening the bathroom door without the resident’s consent.
Failure to Notify Provider of Elevated Heart Rate
Penalty
Summary
The facility failed to notify the resident's physician or nurse practitioner when the resident had a change in vital signs that could have required physician intervention. Resident #2 was admitted in January 2026 with diagnoses including cerebral infarction, hypertension, atherosclerotic heart disease, and inappropriate sinus tachycardia. Review of the resident's heart rates from January 2026 through 3/4/26 showed rates ranging from 57 to 89 beats per minute, with no documented heart rate over 100 beats per minute during that period. On 3/5/26 at 9:00 AM, the resident's March 2026 MAR documented a heart rate of 122 beats per minute. The medical record did not show that the physician or NP was notified of this increase. During interview, the unit manager stated she would expect the physician to be notified because the rate was far outside the resident's usual range and said she would notify the doctor and recheck the heart rate after medication. The NP stated he would expect to be notified about a heart rate of 122 because he would want to know whether the resident was symptomatic, whether the respiratory rate was elevated, or whether other issues such as sepsis, pain, or positioning were contributing.
Incomplete Documentation of Elevated Heart Rate and Medication Administration
Penalty
Summary
The facility failed to maintain complete and accurate medical records for one resident. Resident #2 was admitted with diagnoses including cerebral infarction, hypertension, atherosclerotic heart disease, and inappropriate sinus tachycardia. The resident’s heart rates from one period in the record ranged from 57 to 89 bpm, but the MAR documented a heart rate of 122 bpm at 9:00 AM on one date. Nursing progress notes, evaluations, and the vital sign section of the electronic medical record did not show that the resident’s heart rate was reassessed between 9:00 AM and 8:00 PM, and there was no documentation about whether the heart rate decreased or whether the resident had symptoms related to the elevated heart rate. The MAR also showed that at 8:00 PM the medications Atorvastatin, Famotidine, Metoprolol, and Acetaminophen were signed off as not given because the resident had passed away suddenly. However, a change in condition note documented that the resident was assessed with no pulse, no BP, and no respiration at 10:00 PM, with a code blue and 911 called, and paramedics continuing CPR until the resident was pronounced deceased at 10:36 PM. RN #12 stated she gave the evening medications at 9:00 PM but did not sign the MAR until later, and the DON confirmed that the medical record did not reflect the medications were given or the resident’s status as described in the nurse’s statement.
Failure to Notify Residents When Personal Funds Exceeded Medicaid Resource Limit
Penalty
Summary
The facility failed to notify residents receiving Medicaid benefits to spend down when their personal account balances reached within $200 of the SSI resource limit. A review of the fund management company report dated 4/3/26 showed 8 residents with personal fund accounts above $2,500, including balances ranging from $2,609.96 to $3,235.99. These residents were identified as having funds over the SSI resource limit, and the deficiency involved the facility’s handling of resident personal funds and required notifications. On 4/7/26, the surveyor reviewed Resident Fund Balance Notification letters for the 8 residents. The letters stated that the resident fund balance was within $200 of or exceeding what was allowable under Medical Assistance and asked the resident to contact the social worker within 7 days to discuss ways to assure continuance of Medicaid benefits. Each letter was signed by Staff #24 and by the resident, but several residents had documented cognitive or decision-making limitations. Resident #12, Resident #48, Resident #54, Resident #57, Resident #108, and Resident #129 had physician documentation indicating they were unable to understand and sign admission documents or were incapable of making informed decisions, while Resident #48 also had a court-appointed guardian. Staff #24 stated that when residents approached the $2,500 limit, she gave them a catalog to order items and contacted corporate for money to be moved to burial accounts because she did not have access to move resident monies. She also stated that most of the residents were alert and oriented, that she did not check BIMS scores, and that she did not know what BIMS was. For Resident #57, Staff #24 stated the resident was mute but nodded and understood what was being said. For Resident #129, Staff #24 stated the resident’s loved one signed the letter, while the record showed the spouse signed even though the spouse was not the documented power of attorney and had a BIMS score of 9.
Inaccurate MDS Coding for Multiple Residents
Penalty
Summary
The facility failed to code residents’ status accurately on the MDS for 4 of 6 residents reviewed for assessment accuracy. The report identified errors in multiple MDS sections, including restraints, antipsychotic medication use, language preference, and infection status related to MDRO precautions. These inaccuracies were identified through record review, staff interviews, and surveyor observation. For one resident, the admission MDS coded use of a floor mat alarm under restraints, but staff stated the resident had never used fall mats and had never had restraints. For another resident, the admission MDS stated the resident had not received antipsychotic medication, even though the resident had an active order for Seroquel 25 mg for brief psychotic disorder and the MAR showed daily administration since admission. The MDS coordinator confirmed that the antipsychotic coding was incorrect. For a third resident, the annual MDS coded English as the preferred language and indicated no interpreter was needed, although the resident’s daughter and assigned aide stated the resident primarily spoke Vietnamese and only a few words of English. For a fourth resident, the quarterly MDS stated the resident did not have an MDRO, despite a physician order for enhanced barrier precautions for MDRO and documentation that the resident was positive for Candida auris. Staff confirmed the MDS was inaccurate, and the DON stated the resident had been identified by the state epidemiologist as C. auris positive.
Failure to Educate and Offer Annual COVID-19 Vaccination
Penalty
Summary
The facility failed to educate and offer COVID-19 immunizations to residents who were eligible for vaccination. During the recertification survey, the surveyor requested the facility’s COVID-19 policy and proof that Residents #28, #57, #48, #39, and #12 had been educated and offered the COVID-19 vaccine in 2025. Record review showed that Residents #28, #12, #48, and #57 had received COVID-19 immunizations on 11/11/2024, while Resident #39 was last offered the vaccine in 2023. The facility’s COVID-19 vaccination policy stated that eligible residents were to be educated and offered the vaccine annually. The DON confirmed that the facility offers immunizations annually and acknowledged there was no documentation to support that the vaccines were administered or refused, and that the five residents should have been offered COVID-19 immunizations in 2025.
Failure to Support Communication for a Resident with LEP
Penalty
Summary
The facility failed to provide services to maintain communication abilities for a resident with Limited English Proficiency. Resident #98 stated that he/she did not speak English, and the resident’s daughter confirmed that the resident’s primary language was Vietnamese and that the facility typically called family members to communicate information to the resident. The daughter also stated that she was not aware of the facility ever using a language line to communicate directly with the resident. Record review showed that Resident #98 was admitted to the facility on [DATE], and the admission MDS documented Vietnamese as the resident’s preferred language. A GNA who had cared for the resident for years stated that the resident does not speak English, that staff communicate through gestures or by using items the resident brings to indicate needs, and that she had never seen a communication board or the language line used with the resident. The DON stated that she did not believe staff used a communication board to interact with the resident.
Delayed Reporting of Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of abuse in a timely manner for Resident #139, who alleged that a staff member hit them. Record review showed that Staff #32 became aware of the incident on 12/4/2025 at 9:45 PM, but the Nursing Home Administrator did not become aware until 12/5/2025 at 10:30 AM, and the initial report was not submitted until 12/5/2025 at 12:40 PM. During interview, the NHA stated that staff should report an allegation of abuse to the DON or NHA right away and acknowledged that administration should typically be notified immediately. Review of the facility’s Abuse and Neglect Policy showed that staff are expected to report any allegation of abuse to the Administrator immediately.
Failure to Document Hospital Transfer and Bed Hold Notice for Cognitively Impaired Resident
Penalty
Summary
The facility failed to ensure appropriate provision and documentation of the notice of hospital transfer and bed hold policy to a resident's responsible party. Resident #7 had a 5-day Medicare MDS assessment showing a BIMS score of 02, indicating severe cognitive impairment, and also had a physician's certificate of incapacity dated 01/09/2026 stating the resident was unable to comprehend information or make decisions due to dementia. On 02/01/2026 at 07:08, the resident experienced a change in condition with an oxygen saturation level of 76% and restlessness, and the NP ordered transfer to the hospital for further evaluation and treatment. The follow-up note documented that the resident was admitted with aspiration pneumonia. During record review, the facility produced a notice of hospital transfer and bed hold policy that showed acknowledgment of receipt signed by the resident. However, staff interviews indicated the resident could not understand or sign the documents at the time of transfer because of the resident's cognitive status and altered mental status. The Social Services staff stated the documents had been provided and asked to produce them, while the DON confirmed the resident would not have been able to understand the hospital transfer or sign the bed hold notice and acknowledged the discrepancy when shown the signed acknowledgment.
Failure to Refer Residents With Serious Mental Disorders for Level II PASARR Review
Penalty
Summary
The facility failed to refer two residents with serious mental disorders for a Level II PASARR assessment. One resident was admitted from a hospital with a documented diagnosis of schizoaffective disorder, had a physician order for olanzapine 10 mg daily, and the admission MDS coded schizophrenia and routine antipsychotic use. The PASARR initiated by the hospital did not document the schizophrenia diagnosis or antipsychotic medication and was marked auto approved with no Level II required. Staff stated the facility did not have an updated PASARR for this resident. A second resident was admitted with a diagnosis of bipolar disorder and had a physician order for olanzapine 2.5 mg via PEG at bedtime for bipolar disorder. The admission MDS coded bipolar disorder and indicated use of an antipsychotic medication, but the PASARR initiated by the hospital did not document the bipolar disorder diagnosis or antipsychotic use and was also marked auto approved with no Level II required. Staff stated the facility did not have an updated PASARR for this resident and explained that when a hospital PASARR lacks a psychiatric diagnosis or medication, the facility sometimes resubmits; after surveyor intervention, the PASARRs were amended.
Care Plan Not Updated to Reflect Enhanced Barrier Precautions
Penalty
Summary
The facility failed to review and revise the interdisciplinary care plan to reflect accurate interventions for Resident #129. During record review, the resident was observed on 3/30/26 without indwelling catheters and with wounds on the feet that were covered to contain secretions. The resident’s medical record showed a physician order dated 3/30/26 for Enhanced Barrier Precautions (EBP) to be maintained at all times for MDRO every shift. The care plan in the record was dated 6/12/24 and identified the resident as having infection positive for Candida auris and Candida albicans, with interventions to maintain Contact Precautions. The care plan had not been revised to reflect the March 2026 order for EBP. The DON provided an email dated 6/13/2024 from the Maryland Prevention and Health Promotion Administration’s epidemiologist stating that the resident was Candida auris positive and could be on EBP because C. auris is a CDC-targeted MDRO.
Missing Oxygen Order
Penalty
Summary
The facility failed to maintain professional standards of practice related to oxygen orders for Resident #49. On 03/30/2026 at 9:00 AM, the resident was observed receiving oxygen therapy. On 03/31/2026 at 9:42 AM, record review did not reveal an active order for oxygen for the resident. On 04/01/2026 at 9:25 AM, the concern was brought to the Director of Nursing, who indicated that she understood.
Call Bell Not Kept Within Reach
Penalty
Summary
The facility failed to ensure that a resident had access to the call bell. On multiple observations, Resident #49’s call bell was found on the floor and not within reach of the resident on 03/30/2026 at 8:46 AM, 03/31/2026 at 10:37 AM, 03/31/2026 at 12:18 PM, and 04/01/2026 at 10:20 AM. During an interview on 04/01/2026 at 10:21 AM, a GNA stated that call bells are expected to be within reach at all times and noted that Resident #49 did not have a clip on the call bell cord, making it difficult to keep it within reach. Later that day, the DON stated that call bells are expected to be within reach at all times and be clipped, and indicated understanding when the concern was brought to her attention.
Oxygen Therapy Not Provided per Order and Empty Tank Used
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed was not met for Resident #45, who had an active order for oxygen via nasal cannula at 2 L/min every shift for COPD. Surveyors observed the resident on 3L of oxygen via nasal cannula on two separate occasions, and the resident stated they were supposed to be on 2L of oxygen because of pneumonia. Review of the medical record also showed that the care plan did not include oxygen therapy interventions. In addition, the resident was observed sitting in a wheelchair with the nasal cannula connected to an oxygen tank behind the wheelchair, and the tank was empty. Staff #11 stated she was not aware the resident was connected to an empty tank and said she thought the resident should be on 3L. The administrator acknowledged that the resident's nasal cannula should not have been connected to an empty oxygen tank.
Medication Availability and Timely Administration Failures
Penalty
Summary
The facility failed to ensure that medication was available for administration as ordered for a resident who was admitted on 3/16/2026 with an order for Clonazepam entered the same day. Review of the MAR showed the resident did not receive the medication from 3/16/2026 through 3/20/2026. Nursing notes from 3/17/2026 documented that staff were waiting for the medication from the pharmacy. During interview, the DON stated that for newly admitted residents the provider is supposed to complete a C2 form that is faxed to the pharmacy, and that some providers can also request medications electronically or by calling the pharmacy for verbal release. The facility also failed to administer medications on time for a resident ordered Timolol Maleate Ophthalmic Solution 0.5% 1 drop in both eyes twice daily. The Medication Administration Audit Report showed the eye drops were given more than an hour late 22 times between 12/6/2025 and 12/21/2025 by multiple nurses. The DON confirmed the late administrations and stated that medications should be given at the time they are ordered to be given. The report also states that the minimal standard of practice for timely medication administration is that medications that are not time sensitive are to be given within 1 hour before and 1 hour after the ordered administration time.
Failure to Provide Ordered PT Services
Penalty
Summary
The facility failed to provide physical therapy services as ordered for Resident #6. The resident reported that PT was supposed to occur 3 times per week but rarely happened. Record review showed only 3 PT sessions in February and 5 sessions in March, despite an active order for skilled PT 3-5 times per week for 90 days for therapeutic exercises. The resident’s care plan directed that PT evaluation and treatment be provided as ordered, and a recent PT recertification stated the resident should continue PT 3-5 days per week for therapeutic exercise, neuro re-education, therapeutic activities, gait training, and wheelchair management and mobility. The PT Director stated that although the resident was ordered for 3-5 sessions per week, the facility considered the resident a long-term resident and did its best to accommodate sessions, sometimes providing only one or two sessions per week. The Regional PT Director stated the order should include as needed because the resident had plateaued but could not be discharged from PT services.
Failure to Follow EBP During PICC Line Care
Penalty
Summary
The facility failed to ensure that staff adhered to enhanced barrier precautions when providing care to a resident with a PICC line. Resident #87 had an order for EBP to be maintained at all times for PICC line use every shift for preventive measures, and a yellow sign on the resident’s door indicated that EBP precautions were to be followed when providing care or medications via the PICC line. On 04/03/2026 at 08:30 AM, Staff #31, an agency nurse on her first day at the facility, was observed administering Fluticasone IV medication through the resident’s PICC line while wearing gloves only and not a gown. During interview shortly afterward, the nurse stated she was not aware the resident was on EBP precautions and said she had not yet been provided training. The DON later stated that the facility requires staff to wear gowns and gloves when caring for PICC lines.
Failure to Prevent Elopement of Cognitively Impaired Resident
Penalty
Summary
A cognitively impaired resident with a diagnosis of Alzheimer's Disease and a BIMS score indicating severe cognitive impairment was identified as being at risk for wandering, with a care plan in place that included a wander guard. Despite these measures, the resident was able to exit the facility unsupervised. On the day of the incident, the resident was last seen by a charge nurse in their room. Later, a GNA arriving for her shift heard a soft alarm, which she initially mistook for a call light. Upon investigation with an LPN, they discovered an exit door slightly open and another door leading outside that was unlocked, with the alarm still sounding faintly. After realizing the resident was missing, staff initiated a head count and notified the RN supervisor, who activated the facility's missing resident protocol. The facility conducted a search of the building and surrounding neighborhood, and local law enforcement was called to assist. The resident's family was notified, and the search continued into the evening with the involvement of police and specialized search equipment. The resident was eventually found the next morning in a wooded area near the facility by a staff member. The investigation revealed that the resident was able to leave through an exit door due to a very low-volume alarm that was barely audible from the nursing station. The resident had not previously eloped. The incident highlighted a failure to prevent a resident at risk for wandering from exiting the facility unsupervised, as well as issues with the effectiveness and audibility of the door alarm system at the time of the event.
Failure to Address and Document Significant Weight Loss
Penalty
Summary
A resident experienced a significant weight loss of 13 pounds (10%) within one month, as documented in the medical record. The resident's nutrition care plan included an intervention to notify the physician and dietitian of any significant weight changes. However, there was no documentation that the significant weight loss was addressed by either the physician or the dietitian. The discharge summary from the previous provider noted the resident's morbid obesity but did not address the recent weight loss. Interviews with the Medical Director and the dietitian confirmed that the weight loss was not specifically addressed or documented. The dietitian stated that the usual process would be to discuss supplements with the resident and initiate them if desired, but could not confirm if this occurred due to lack of documentation. Both staff members indicated that significant weight loss is typically discussed in risk management meetings, but there was no evidence in the record that interventions or changes were made in response to this resident's weight loss.
Failure to Provide Dignified Dining Experience and Timely Feeding Assistance
Penalty
Summary
During a dinner observation, a resident was seated in a geri-chair at a dining table with another resident who was independently feeding themselves. The resident in the geri-chair did not have a plate of food in front of them and was left waiting to be fed, with only two cups (one containing juice) placed on the table. Staff in the dining room were observed assisting other residents, including responding to a juice spill and discarding utensils that had fallen on the floor, but did not sanitize their hands before continuing to assist with feeding. Despite four staff members being present in the dining room, none attempted to feed the resident in the geri-chair during this time. The resident remained without a meal and unattended for approximately 26 minutes until another staff member, who had been serving trays to residents in their rooms, began to feed them. Staff interviews confirmed that staffing levels were low and that many residents required assistance with feeding. It was also stated that all staff are expected to assist with feeding residents, but this expectation was not met during the observed dining period.
Failure to Maintain Sanitary Conditions in Clean Utility Rooms
Penalty
Summary
The facility failed to maintain a sanitary environment in two out of two clean utility rooms observed during the recertification survey. On the second floor, Forest View clean utility room, two intravenous poles were found with brown and gray colored solid matter covering their bases, and neither pole had a label indicating they were clean. On the first floor, Chapel Valley clean utility room, three intravenous poles with brown and white colored substances at their bases and one oxygen concentrator covered with gray solid matter were observed, with none of these items labeled as clean. During an interview, the Central Supply Clerk confirmed that these items were dirty and should not have been placed in the clean utility room, stating that they should have been placed in the soiled utility room and labeled or bagged after cleaning.
Failure to Obtain Ordered GI Consultation
Penalty
Summary
A physician order was present in the medical record for a gastrointestinal (GI) consultation for a resident experiencing poor oral intake and weight loss. Review of the resident's medical record did not show any evidence that the GI consultation had been completed or scheduled as ordered. During an interview, the Director of Nursing confirmed that the consultation should have been scheduled and indicated that she would investigate the matter. The deficiency was identified due to the facility's failure to obtain the GI consultation as requested by the physician.
Failure to Address Significant Weight Loss in Resident
Penalty
Summary
Facility staff failed to address the nutritional needs of a resident with a known history of significant weight loss. The resident, diagnosed with diverticulitis, experienced ongoing difficulty with food intake, including being unable to keep food down and having large bowel movements after eating. Medical records showed a substantial decrease in weight over several months, with the system generating multiple significant weight loss alerts. Despite these warnings, there was no documentation of new interventions or physician notification after an initial order for a nutritional supplement was made. Interviews with staff revealed that while there were processes in place for monitoring and documenting weight changes, these were not followed for this resident. The Registered Dietician was responsible for making dietary recommendations and notifying the physician, but could not explain why further actions were not taken. Nursing staff described the process for recording weights and responding to alerts, but were unable to account for the lack of response to the resident's ongoing weight loss.
Physician Documentation Lapses for Residents with Significant Weight Loss
Penalty
Summary
The facility failed to ensure that physicians documented the medical history and treatment plans for residents experiencing significant weight loss. In one case, a resident experienced a 17.5-pound (10.7%) weight loss over a three-month period, as documented by the dietician. Despite ongoing dietary interventions and regular monitoring by the dietician and staff, there was no physician or nurse practitioner note in the medical record detailing the treatment plan or summarizing the medical conditions impacting the resident's weight fluctuations. The medical director confirmed that no such progress note had been written for this resident. In another instance, a resident with a complex medical history, including edema, gout, diverticulitis, asthma, nicotine dependence, hyperlipidemia, and lack of coordination, experienced significant weight loss. The medical director acknowledged during an interview that a diagnosis of Anasarca was not documented in the resident's medical chart, despite being aware of the condition. The absence of documentation regarding the resident's medical history and treatment plan was confirmed during the survey, and the medical director admitted to the oversight.
Failure to Serve Hot Foods at Safe and Appetizing Temperatures
Penalty
Summary
Surveyor observation determined that the facility failed to provide palatable food at an appetizing and safe temperature for residents. During a test tray check at the end of food service in the Chapel Way dining area, three hot food items were measured using the facility's thermometer by a staff member. The potatoes registered at 119.8°F, the spinach at 109.2°F, and the meat (veal) at 123.1°F, all of which were below the required internal temperature of 135°F for hot foods. The Regional Dietary Manager confirmed these temperatures during an interview.
Failure to Maintain Sanitary Food Service Practices and Cleanliness
Penalty
Summary
Surveyors observed multiple lapses in sanitary practices and cleanliness within the facility's kitchen during an initial tour with the Regional Dietary Manager. Specifically, seven repoured and unlabeled applesauce containers were found on a dirty utility table, a large white laundry basket containing soiled white linens was present in the dry storage room, and food along with a liquid substance was noted on the kitchen floor near the walk-in freezer. Additionally, a red substance had spilled over metal shelves in the walk-in refrigerator, and the area designated for rinsing dirty dishes was unkempt with food particles left in the strainer. These findings indicate that the facility failed to maintain food service safety and a clean working environment in accordance with professional standards.
Failure to Document and Address Significant Weight Loss in Residents
Penalty
Summary
The facility failed to properly document and address significant weight loss in two residents, as required by accepted professional standards. For one resident, there was a documented weight loss of 13 pounds (10%) within one month, but the medical record lacked evidence that the physician or dietitian was notified, and there was no documentation of interventions or changes to the resident's care plan. The dietitian confirmed during an interview that he could not provide documentation of any actions taken in response to the weight loss and admitted that such changes and interventions were not recorded. For another resident, records showed a substantial weight fluctuation following a hospital discharge, with a notable decrease over subsequent months. Despite this, there was no documentation that the resident's weight loss was monitored, addressed, or that the physician was notified. Interviews with the registered dietitian and nurse unit manager revealed that required forms and notifications were not completed, and review of risk management meeting minutes showed no mention of the resident's weight loss. The director of nursing was unable to provide documentation of any change in condition or physician notification related to the resident's weight loss.
Failure to Perform Hand Hygiene After Handling Contaminated Items
Penalty
Summary
Facility staff failed to adhere to infection control practices during a dinner service observation. A resident spilled juice onto their plate while feeding themselves, prompting a staff member to remove the plate. Before returning to assist the resident, the staff member picked up utensils that had fallen onto the floor from another resident and discarded them, but did not perform hand hygiene before resuming assistance. The staff member acknowledged the lapse when interviewed, stating she believed using a napkin was sufficient and that she would use proper infection control practices in the future. These actions were directly observed by surveyors, who noted the lack of hand sanitization between handling potentially contaminated items and providing direct care to a resident.
Failure to Consistently Honor Resident Food Preferences
Penalty
Summary
The facility failed to honor residents' food preferences, as evidenced by observations, interviews, and medical record reviews. During meal service, residents reported that they were often served food items that did not match their stated preferences, and the menu slips on resident trays primarily listed dietary restrictions due to diagnoses or allergies, rather than individual food preferences. Staff interviews confirmed that menu slips did not consistently include residents' preferred food items, and staff would serve meals without verifying if residents received their preferred choices. For example, one resident expressed dissatisfaction with receiving a biscuit instead of toast and a boiled egg instead of scrambled eggs, while another resident noted a preference for boiled eggs and a dislike for cream of wheat, which was not always honored. Further, the Certified Dietary Manager acknowledged that the current system focused on avoiding restricted foods but lacked a process to ensure residents' preferences were consistently met. Observations showed that most menu slips did not disclose food preferences, and staff relied on the slips for guidance without additional verification. The lack of a check and balance system contributed to residents not consistently receiving meals according to their preferences, as confirmed by both dietary and nursing staff.
Failure to Supervise Resident Leading to Unauthorized Leave
Penalty
Summary
The facility staff failed to provide adequate supervision to prevent an accident involving a resident who was assessed to be at low risk for elopement. The resident, who was admitted for rehabilitation, left the facility without a physician's order for a therapeutic leave of absence. The incident occurred when the resident, unaware of the cancellation of a church service within the facility, decided to attend a church in the community. The resident was found outside the facility by the police and returned without injuries. Upon review, it was discovered that the resident did not have a physician's order for a leave of absence at the time of the elopement. The facility's Therapeutic Leave Policy requires a physician's order and documentation in the medical record for any leave of absence. The deficiency was confirmed during an interview with a nurse consultant, who acknowledged the failure to provide supervision for the resident.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 1,919 citations issued within 25 miles in the last 12 months — including the 16 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Burtonsville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Fairland Center | 2 mi | ★★★★★ | 4 | 0 |
| Autumn Lake Healthcare At Silver Spring | 2.2 mi | ★★★★★ | 15 | 0 |
| Riderwood Village | 3 mi | ★★★★★ | 17 | 0 |
| Harmony Suites Rehabilitation And Wellness Center | 3.4 mi | ★★★★★ | 6 | 1 |
| Autumn Lake Healthcare At Patuxent River | 3.4 mi | ★★★★★ | 23 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.