Average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
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 Patuxent River during CMS and state inspections, most recent first.
Facility staff did not consistently administer and document medications according to physician orders for two residents. One resident admitted for strict diabetic monitoring and wound healing had scheduled Novolog and sliding-scale insulin doses that were repeatedly signed off well after the ordered administration times, with blood glucose values ranging widely. Another resident receiving Midodrine for hypotension had ordered BP checks and concurrent dosing at specific times, but vital signs and MAR entries showed inconsistent timing, with morning doses documented hours late and BP readings not matching the ordered schedule. These findings reflect failures in timely medication administration and immediate documentation.
The facility failed to ensure accurate MDS assessments of a resident’s lower extremity function. A bedbound resident with a healed leg wound had earlier MDS assessments coded with bilateral lower extremity impairments, while later assessments were coded as no impairment. The MDS coordinator reported coding no impairment if she could move the limb passively, even though the resident could not follow directions to move independently, and stated she just codes what is presented at the time. During observation, an LPN had difficulty repositioning the resident’s legs, and the MDS nurse demonstrated her assessment by passively flexing the ankle and stating that it was moving, leading surveyors to determine that the MDS coding did not accurately represent the resident’s functional status.
A resident’s medical record did not contain the most recent physician visit note, despite the resident having been seen by a new attending physician. During surveyor review, the only attending physician note available was several months old, and the DON initially confirmed that no newer note was in the chart. It was later shown that the resident had been seen by the new attending physician, but that visit note had not been placed in or made available within the medical record.
A resident on enhanced barrier precautions (EBP) was observed receiving incontinent care from a GNA who was not wearing a gown, despite EBP signage on the door and an orange-highlighted name tag indicating EBP status. The GNA reported he had removed the gown before finishing care because it was in his way and admitted he knew EBP required gown and glove use but was unsure which resident the sign referred to. Surveyors also observed an uncovered linen cart in the room’s doorway with exposed linen, as well as linens on the floor and a plastic bag of linen next to them. An LPN confirmed the resident had physician orders for EBP and agreed the cart should have been covered, while the DON and NHA acknowledged that staff should have followed the EBP signage and orange-highlighted tag.
A resident was found without access to their call bell plunger on two occasions, with the device observed on the floor and later hanging down from the bed. The resident was unable to locate the call bell when asked, indicating staff did not ensure the resident could reach it.
A resident developed a new rash and pressure ulcer that was identified during routine skin assessments, but staff failed to notify the physician of this change. Although the resident had a history of skin issues and was receiving daily topical treatment, the new impairment was not communicated to the physician, and staff applied a non-prescribed cream without proper documentation or notification.
Surveyors identified that facility staff did not develop or implement complete care plans for two residents, failing to address one resident's repeated shower refusals and another resident's transfer assistance needs. Care plans lacked specific interventions, and documentation of care needs was inconsistent, with staff interviews revealing confusion about care instructions and transfer status.
Facility staff did not document the reason for a missed dose of Vitamin C medication for a resident with an active order for anemia treatment. When the MAR indicated to 'See Nurse Note' for the missed dose, the DON was unable to find any supporting nurse note or explanation in the medical record.
Multiple infection control deficiencies were observed, including a trach collar oxygen mask left on the floor for a resident with a tracheostomy, a used Foley catheter placed on a bedside table instead of being discarded, and staff entering rooms of residents on contact precautions without performing hand hygiene or wearing PPE. Staff interviews confirmed lapses in following infection prevention protocols and a lack of understanding of contact precaution requirements.
A facility failed to maintain the dignity of two residents. One resident’s clothing bin had clothing covered by an empty milk carton, a bowl with old food, and a bag with used disposable dinnerware, and the items remained in place on follow-up observation. Another resident’s Foley bag was observed on the floor with cloudy yellow urine, and later the bag was seen on a bedside table while the resident had a nearly full urinary leg Foley.
The facility failed to address a resident’s request to complete an advance directive, failed to keep accurate advance directive records for another resident whose chart contained the wrong POA paperwork and an incomplete incapacity certification, and failed to offer advance directive information to a capable resident. The DON and SW confirmed missing or incorrect documentation, and one resident’s requested advance directive was only found after surveyor intervention.
Failure to care plan an indwelling urinary catheter: A resident had an active Foley order, a UTI diagnosis, and a contact precautions order, but the care plan and EBP focus initially did not include the catheter. The DON confirmed the catheter was not on the care plan, and the kardex used by GNA staff also omitted it; the resident was observed with a Foley in place.
A resident had an unclarified oxycodone order that listed two different PRN frequencies for the same pain level, and the medication was administered on multiple days under that order. Another resident with CHF, HTN, and lymphedema had daily weights and scheduled cardiac meds completed late, with the NHA and DON acknowledging the timing was not as expected.
A resident was observed in bed with no activities occurring in the room and no evidence of engagement in individualized activity. When the surveyor requested the last 30 days of activity records, staff found no documented activities in the EMR or activity logbook. Staff reported that musical encounters occur about twice a month, but there was no documentation confirming the resident participated in those or any other activities.
Incomplete physician certification forms were found for a resident’s advanced directives review. Surveyors observed that one form had the wrong first name at the top and another copy had the resident’s name, but both physician certification forms were left blank in key sections for patient identification, certifying practitioner selection, and the time-frame statement, even though they were signed by the physician.
A resident did not receive required face-to-face physician visits at least every 60 days after the first 90 days post-admission. Record review showed only one MD note initially, and a later late-entry note documented a physician visit that occurred 124 days after the prior visit. The NHA and DON agreed the visit was late and outside the regulation.
A resident’s chart contained incomplete and inaccurate advance directive/incapacity documentation, including a physician incapacity form missing identifying information and a POA document that did not belong to the resident. The record also lacked the required second incapacity certification, while the care plan referenced a MOLST and advance directive that were not present in the chart. In addition, five resident hard charts had room numbers on the spine that did not match the residents’ actual room locations, and the Administrator confirmed staff use the hard copy records to follow MOLST orders in emergencies.
Multiple residents were served meals that did not match their documented preferences, with frequent omissions, substitutions, and poor food quality reported. Staff interviews revealed miscommunication, supply shortages, and repeated errors on the tray line, resulting in residents receiving unappealing or incorrect food and beverages. The NHA confirmed that meals were not visually appealing and did not match tray tickets, and residents' complaints about meal service were not consistently addressed.
Surveyors found that several residents were using wheelchairs with cracked or missing vinyl on the armrests, and some residents reported that the wheelchairs had been in poor condition for a while. Despite weekly audits by the Director of Maintenance, these issues persisted and were observed on multiple nursing units.
The facility did not report allegations of abuse, neglect, or injury of unknown origin to the regulatory agency within the required 2-hour timeframe for two residents. In one case, a resident with unexplained bruising was not promptly reported, and in another, an allegation of inappropriate touching was not reported within the mandated period. Facility leadership confirmed the delays in reporting.
The facility did not thoroughly investigate multiple abuse allegations, including incidents involving a resident being restrained by staff, a dependent resident found with facial injuries, and a report of inappropriate conduct by staff. In each case, the investigations lacked interviews with all relevant staff or other residents, resulting in incomplete documentation of the alleged events.
A resident requiring extensive ADL assistance after a lumbar fracture did not have documentation showing they were offered or refused showers on assigned days. The DON confirmed there was no record of showers being offered or refused, and only bed baths were documented for a period.
A resident with severe cognitive impairment and a history of falls did not receive neurological checks and vital sign assessments at the required intervals following two separate falls, including one with a head injury. Facility staff failed to document timely neurological evaluations and often reused previous vital signs for multiple checks, contrary to facility policy. Interviews with LPNs, the DON, and the Administrator confirmed that the required protocols for post-fall neurological assessments were not followed.
A resident with significant atherosclerosis and a documented need for routine foot care was not seen by the podiatrist as scheduled for follow-up care. Despite a podiatrist's order for at-risk foot care, facility records and staff interviews confirmed the resident did not receive the required podiatry services on the scheduled date.
A medication cart was left unlocked and unattended in a hallway, allowing access to all medications inside. An LPN and a unit manager were present during the surveyor's observation, and the facility's policy requiring locked storage of drugs and biologicals was not followed.
A resident with a tracheostomy did not attend a scheduled follow-up appointment with a head and neck surgery specialist after being seen by an ENT, as required. Facility staff did not ensure timely access to outside professional services, and this lapse was confirmed by the administrator during a complaint survey.
A resident's medical record lacked documentation of multiple podiatry visits, despite those visits having occurred. The missing records were due to confusion following a change in medical records staff, resulting in incomplete and inaccurate documentation until the issue was identified during a survey.
Failure to Administer and Document Medications per Physician Orders
Penalty
Summary
Facility staff failed to administer and document medications according to physician orders for two residents. For one resident admitted for strict diabetic monitoring related to wound healing, hospital discharge instructions and facility orders required Novolog FlexPen 7 units prior to meals at 6:30, 11:30, 16:30, and 20:00, along with a sliding scale insulin regimen at the same times. Review of the MAR showed multiple instances where insulin doses were signed off significantly later than the scheduled times, including a 16:30 dose signed at 19:23, an 11:30 dose signed at 13:02, and other 11:30, 16:30, and 20:00 doses signed between 1–3 hours late on various dates. Blood glucose values for this resident during the review period ranged from 70 mg/dL to 349 mg/dL. The report notes that late administration is defined as giving medication more than one hour after it is due, and late documentation is defined as not documenting immediately after administration. For another resident, review of the medical record following a facility-reported incident and family concerns about care revealed inconsistencies in nursing notes, vital signs, and ordered medications. The resident had an order for blood pressure checks at 08:00, 12:00, 16:00, and 20:00, to be performed with concurrent administration of Midodrine for low blood pressure. The electronic record showed blood pressure readings at 10:38 and 14:06, which did not align with the ordered schedule, and the MAR indicated that an 08:00 Midodrine dose on one date was signed off at 10:07, and on another date the 08:00 dose was signed off at 12:03, four hours after the scheduled time. The resident was sent to the emergency room on a later date due to hypotension. The report emphasizes that inaccurate and late documentation of medication administration represents a failure of basic medication administration principles.
Inaccurate MDS Coding of Lower Extremity Function
Penalty
Summary
The deficiency involves the facility’s failure to complete accurate MDS assessments of a resident’s functional use of lower extremities. Resident #1, who was bedbound and had a healed, treated wound on the inside of the leg with interventions in place, had multiple MDS assessments reviewed in connection with an injury of unknown origin. The 2/26/25, 5/30/25, and 8/28/25 MDS assessments documented bilateral lower extremity impairments, but the 11/24/25 and 3/4/26 MDS assessments documented no impairment of the bilateral lower extremities. During interview, the MDS coordinator stated that if she was able to move an extremity, she coded it as no impairment, even if the movement was passive and the resident could not follow directions to move independently, and that she “just codes what is presented at the time.” On observation with the assigned nurse (LPN #11), the surveyor noted that the resident’s legs were difficult to move when the nurse attempted to reposition them. When the MDS nurse was brought to the room and asked to demonstrate her assessment method, she flexed the resident’s left ankle back and forth and stated that “it’s moving” when asked if she considered that full flexion. These observations and interviews showed that the MDS assessments did not accurately reflect the resident’s true functional status of the lower extremities, resulting in inconsistent coding of impairment versus no impairment on successive quarterly and annual MDS assessments.
Missing Physician Visit Note in Resident Medical Record
Penalty
Summary
Facility staff failed to ensure that physician visit notes were available in the medical record for a resident, as required. During a record review on 4/9/26, surveyors found that the last attending physician note in the resident’s chart was dated 11/30/25. When additional documentation was requested on 4/10/26, the DON initially did not provide a more recent physician note and confirmed that 11/30/25 was the last attending physician note available in the record. The DON stated she believed the resident had been seen by a new attending physician who started on 3/23/26. Later that same day, the DON produced evidence that the resident had in fact been seen by the new attending physician on 3/26/26, but this visit note had not been placed in or made available within the resident’s medical record. This deficiency centers on the absence of the most recent physician progress note in the resident’s medical record despite the resident having been seen by the new attending physician, resulting in an incomplete and outdated record at the time of survey review.
Failure to Follow Enhanced Barrier Precautions and Linen Handling Practices
Penalty
Summary
The deficiency involves a failure to ensure that infection prevention and control orders, specifically enhanced barrier precautions (EBP), were consistently followed for a resident on EBP. During an observation, a Geriatric Nursing Assistant (GNA) was seen in the resident’s room without a gown while providing incontinent care, despite signage on the door indicating EBP and the resident’s name tag being highlighted orange. The GNA stated he had been wearing a gown but removed it before completing care because it was in his way. He acknowledged that under EBP he was supposed to wear a gown and gloves during care but was unsure which resident the sign applied to. Additional observations showed a linen cart positioned in the doorway of the resident’s room with the blue cover pulled up, leaving linen exposed, and linens lying directly on the floor inside the room with a plastic bag of linen next to them. When interviewed, the GNA agreed that placing linens on the floor and leaving the linen cart open at the doorway was inappropriate due to contamination concerns. An LPN confirmed via physician orders that the resident was on EBP and agreed the laundry cart should have been covered. The DON and Nursing Home Administrator later stated they did not think the resident was on EBP but confirmed that the orange-highlighted name tag indicated EBP and agreed that staff should have followed the posted signage and tag.
Failure to Ensure Resident Access to Call Bell
Penalty
Summary
Facility staff failed to ensure that a resident had access to their call bell plunger, which is necessary for alerting staff when assistance is needed. On two separate occasions, the call bell plunger was observed to be inaccessible: first, it was found on the floor on the right side of the bed, and later it was seen hanging down from the bed near the top of the right-side transition rail. When asked about the location of the call bell, the resident was unable to identify where it was. These observations were made during a complaint survey and confirmed through staff interviews.
Failure to Notify Physician of Change in Skin Condition
Penalty
Summary
The facility failed to ensure that a physician was notified of a change in a resident's skin condition. Weekly skin evaluations for the resident initially showed no issues, but a later assessment identified a rash and pressure ulcer. Despite this change, there was no documented evidence that the physician was informed. Interviews revealed that staff were aware of the skin impairment, with a GNA applying a non-prescribed cream and the nurse unaware of the issue, even though the nurse had documented the skin impairment in a prior assessment. The care plan indicated a history of periodic skin dermatitis, and the resident was on a daily topical treatment, but the new rash and pressure ulcer represented a change that was not communicated to the physician. Observations confirmed the presence of a large dry area and a small open area on the resident's skin. The GNA reported noticing the issue about a month prior and had been applying a cream not ordered for the condition. The nurse and unit manager were not aware of the current skin impairment until informed by the surveyor, and the Director of Nursing confirmed that the new rash should have been reported to the physician. No documentation was provided to show that the physician was notified of the change in the resident's condition.
Failure to Develop and Implement Comprehensive Care Plans for Resident Needs
Penalty
Summary
Facility staff failed to develop and implement comprehensive care plans that addressed all of the residents' needs, as evidenced by two specific cases identified during a complaint survey. In the first case, a resident who frequently refused showers did not have a care plan intervention addressing these refusals. Although the resident was offered showers weekly and received bed baths when showers were refused, the care plan only stated that showers were to be offered twice weekly and did not include strategies or interventions to address or manage the refusals. The Director of Nursing confirmed that the care plan lacked interventions for refusals and acknowledged the need for review. In the second case, a newly admitted resident's transfer status was not assessed or documented in the care plan in a timely manner. The admission screener did not contain information on the resident's ability to transfer, and although the MDS assessment indicated the resident was dependent for transfers, the care plan did not include a transfer intervention until after an incident resulting in injury. Documentation of the resident's transfer assistance needs was inconsistent throughout the month, and staff interviews revealed confusion and lack of clarity regarding the resident's transfer status and the appropriate method for transfers. The care plan was only updated to include a transfer intervention after the injury occurred. Multiple staff interviews confirmed that there was a lack of communication and documentation regarding transfer status, with some staff unsure where to find this information in the medical record. The Director of Nursing and other staff acknowledged that the care plan should have included the resident's transfer status to guide care. The failure to timely and accurately update care plans to reflect residents' needs, including interventions for shower refusals and transfer assistance, led to deficiencies in meeting regulatory requirements for comprehensive, individualized care planning.
Failure to Document Missed Medication Dose in Medical Record
Penalty
Summary
Facility staff failed to maintain the accuracy of a resident's medical record by not documenting the reason for a missed dose of medication. During a complaint survey, a resident reported not receiving their prescribed Vitamin C medication for several days. Review of the medical record showed an active order for Vitron-C Oral Tablet to be administered every other day for anemia. Examination of the Medication Administration Record (MAR) revealed that on one date, the nurse's initials were accompanied by the number '9', which, according to the MAR legend, indicated 'See Nurse Note.' However, upon request, the Director of Nursing (DON) was unable to locate any corresponding nurse note or documentation explaining whether the medication was given or the reason for the missed dose. The absence of this documentation in the medical record was acknowledged by the DON.
Infection Control Lapses in Tracheostomy, Foley Catheter, and Contact Precaution Care
Penalty
Summary
The facility failed to maintain infection prevention and control practices in several instances involving residents with specialized care needs. One resident with a tracheostomy was observed with their trach collar oxygen mask lying on the floor next to the bed on two separate occasions, with the mask dated several days prior. The mask was not replaced until after the issue was brought to the attention of the unit manager, who confirmed the mask had been on the floor and acknowledged the importance of infection prevention in this context. Another deficiency was observed with a resident who had a Foley catheter. A used Foley catheter with visible urine in the tubing and collection bag was found placed directly on the bedside table next to personal care items, rather than being immediately discarded in a biohazard receptacle as required by facility policy. The nurse responsible admitted to forgetting to dispose of the catheter and acknowledged that this action was against infection control policy, which was confirmed by both the Infection Preventionist and the Director of Nursing. Additional infection control lapses were identified with two residents on contact precautions. Staff were observed entering rooms with posted contact precaution signage without performing hand hygiene or donning required personal protective equipment (PPE), and in one case, a staff member handled items on the floor and exited the room without PPE or hand hygiene. Staff interviews revealed a lack of understanding or adherence to contact precaution protocols, and in some cases, staff were unaware of the reasons for the precautions. These failures were confirmed by supervisory staff and the infection prevention team during interviews.
Dignity Concerns With Room Clutter and Foley Bag Placement
Penalty
Summary
The facility failed to maintain the dignity of two residents. In one room, a brown clothing bin with the top missing and two drawers underneath was observed with clothing under an empty milk carton, along with a black plastic bowl containing old food and a clear plastic bag with used disposable dinnerware placed on top of the resident’s clothing. On follow-up observation, the clothing bin was covered with a clean towel, but the empty milk carton, the bowl with old food, and the bag with used disposable dinnerware were still on top of the resident’s clothing. A GNA stated the clothing bin had been like that for a while and was unsure who was responsible for placing the items there. The Unit Manager stated residents’ rooms should remain clean and organized and personal items should be stored appropriately to maintain dignity, and confirmed the items should have been removed after the initial observation. For the second resident, the Foley catheter bag was observed containing approximately 600 cc of cloudy yellow urine and resting directly on the floor. The Unit Manager was notified, removed the bag from the floor, and emptied it. On a later observation, the Foley bag was lying on the bedside table with approximately 100 cc of urine, and when asked if the Foley had been discontinued, the resident pulled back the covers and revealed a urinary leg Foley that was nearly full.
Advance Directive Documentation and Offer Process Failures
Penalty
Summary
The facility failed to ensure that residents’ requests to implement advance directives were addressed, that advance directive information was offered, and that advance directive documentation in the medical record was accurate and followed. This was identified for 3 of 66 residents reviewed: Resident #10, Resident #117, and Resident #106. For Resident #10, the admission advance directive evaluation form completed on 05/26/25 showed the resident answered yes to wanting to meet with Social Work to discuss steps to implement an advance directive. Surveyors could not locate an advance directive in the chart at the time of review. The Director of Social Work confirmed the resident had requested to implement an advance directive and stated an advance directive could not be located in the chart. A completed Maryland Advance Directive form dated 07/30/25 was later provided after surveyor intervention. For Resident #117, the record showed the resident was admitted in March 2025 and had a physician certification of incapacity dated 06/17/25, but the form did not include the resident’s name. The resident’s MOLST form indicated a surrogate decision-maker dated 04/01/25, and the advance directive in the chart was a power of attorney for a person with a different first name and was not Resident #117’s document. The Administrator confirmed the resident was incapable of medical decision making, and the Social Worker acknowledged the power of attorney paperwork in the chart was not the resident’s and was an oversight. For Resident #106, the record showed the resident was capable of making their own medical decisions, but no advance directive was present and no documentation showed that advance directive information had been offered; the DON and Social Worker both confirmed no advance directive or record of an offer could be located, and the resident had still not been offered the information when rechecked later that day.
Failure to Care Plan Indwelling Urinary Catheter
Penalty
Summary
The facility failed to ensure Resident #117’s care plan was comprehensive for an indwelling urinary catheter. Record review showed the resident had an active order for an indwelling urinary catheter beginning 3/31/25, with diagnoses including urinary tract infection, and an active order beginning 6/15/25 for contact precautions. However, on 8/4/25 the resident’s care plan had no documentation of the urinary catheter, and the enhanced barrier precautions focus did not include a catheter as one of the listed indications. The baseline care plan reviewed on 8/4/25 documented that the resident had an indwelling catheter present on admission, but the ongoing care plan did not reflect that condition. During observation on 8/4/25, the surveyor saw Resident #117 had a Foley catheter in place. The DON confirmed the catheter was not care planned and stated that nothing was on the care plan for the resident’s catheter. The kardex used by GNA staff also had no mention of the urinary catheter. The care plan later reviewed on 8/6/25 showed documentation initiated on 8/5/25 that the resident had an indwelling urinary catheter, along with goals and interventions for catheter care and a goal related to urinary infection.
Unclarified pain order and late medication and weight administration
Penalty
Summary
The facility failed to clarify a pain medication order for Resident #24 and the medication was administered under an order that contained two different administration frequencies for the same pain level. The medical record showed an order dated 11/06/2024 for oxycodone HCl 10 mg by mouth every 6 hours as needed for pain (5-10) and also every 4 hours as needed for pain (5-10) within the same order. The MAR for 07/01/2025 through 07/31/2025 showed oxycodone HCl was given on 17 days of the month. During interview, the NHA and DON stated the order should have been clarified, and they later stated the order was discontinued after surveyor intervention and discussion. The facility also failed to administer medications and obtain daily weights for Resident #14 at the ordered times. The resident had a history of essential primary hypertension, chronic combined systolic and diastolic CHF, and lymphedema. Physician orders included daily weights at the same time every day and cardiac medications including losartan, carvedilol, and Lasix. Record review showed weights scheduled for 07:00 AM were completed at 13:56 on one day and 10:14 on another, and scheduled medications were documented as given several hours late on 07/29/25, 07/30/25, and 07/31/25. The NHA and DON acknowledged that the medications and weight monitoring were administered late and stated this was not the expectation.
Failure to Provide and Document Individualized Activities
Penalty
Summary
The facility failed to provide and document individualized activities to support the physical, mental, and psychosocial well-being of Resident #6, who was observed lying in bed with no activities occurring in the room or any evidence of engagement in individualized activity on 07/30/2025 and again on 08/01/2025. When the surveyor requested the last 30 days of activity documentation, Staff #4 checked the electronic medical record and stated there were no recorded activities for the resident, and also could not locate any documentation in the activity department's logbook. Staff #4 stated that musical encounters with a musician, typically a guitarist visiting residents' rooms, occur approximately twice a month, but there was no documentation to confirm the resident's participation in these or any other activities.
Incomplete physician certification forms for advanced directives
Penalty
Summary
The facility failed to ensure a resident’s care was reviewed by the physician for advanced directives. During record review, surveyors found a second certification of incapacity form dated 6/19/25 for Resident #117 that had a different first name with the same last name written at the top instead of the resident’s name. An additional copy of the certification of incapacity form was also reviewed and had the resident’s name at the top, but both physician certification forms related to medical condition, substitute decision making, and treatment limitations were left blank in Part 1 for the patient identification statement, the certifying practitioner selection, and the time frame statement. Both forms were dated 6/19/25 and signed by Physician #8. On 8/4/25, the surveyor shared the concern with the Administrator, who observed, confirmed, and acknowledged understanding. On 8/6/25, the Administrator and DON were interviewed, and Physician #8 stated by phone that the facility social worker asked them to come into the facility to sign forms left at the desk, which they did on 8/4/25. The concern was again shared with the Administrator and DON, and later during the exit conference with the Administrator, DON, and Corporate Compliance Nurse.
Late Physician Visit Beyond Required 60-Day Interval
Penalty
Summary
The facility failed to ensure that Resident #24 was seen face-to-face by a physician at least once every 60 days after the first 90 days following admission. During record review, the resident’s chart showed an MD General Note dated 01/10/2025 created by Physician #08, and no other MD General Notes for subsequent dates of service were found during the review. Surveyors raised the concern with the NHA and DON during interview, and later the facility provided a late-entry MD General Note dated 05/14/25 that had been created on 08/04/25. The 05/14/25 physician visit occurred 124 days after the prior physician visit on 01/10/25, and the NHA and DON agreed that this timeframe was outside the regulation and that the physician visit was late.
Inaccurate Medical Records and Room Labeling
Penalty
Summary
The facility failed to ensure the accuracy and completeness of Resident #117’s medical record. The record contained a physician certification of incapacity dated 6/17/25 that did not include the resident’s name in the identifying information section. During interview, the Administrator confirmed the resident was incapable of medical decision making and stated that two certifications for incapacity were required. When the surveyor reviewed the record with the Administrator, only one certification of incapacity was present, and the power of attorney advance directive in the chart was not Resident #117’s. The Administrator stated that the social worker had further information in her office in case documentation was misplaced or sent to the hospital. On further review, the care plan for Resident #117 referenced a MOLST form and stated that the resident had an advance directive, with an intervention to review the MOLST with the resident/POA quarterly and as needed. However, the surveyor found no second certification of incapacity and no advance directive for Resident #117 in the medical record at that time. The Social Worker confirmed that the power of attorney paperwork in the chart was not the resident’s and said this was an oversight. She also stated that the resident’s family member was contacted and confirmed that Resident #117 has a power of attorney, which the family member would bring to the facility the next day. The facility also failed to ensure accuracy of room numbers on hard copy medical records located on the lighthouse unit. The surveyor observed that the room numbers labeled on the spines of five resident charts did not match the rooms where the residents were located, and did not match the room number labeling of the areas where they were kept. The Administrator confirmed that staff refer directly to the hard copy medical records to follow the MOLST in emergencies. The resident census review confirmed five hard copy medical records with room numbers that did not match the residents’ actual locations, and the charts were stored in areas labeled with conflicting room numbers.
Failure to Provide Palatable, Appealing, and Accurate Meal Service
Penalty
Summary
The facility failed to provide residents with food and beverages that were palatable, appealing, and matched their documented preferences as indicated on tray tickets. Multiple residents received meals that did not correspond to their selections, such as being served the wrong type of bread, juice, or milk, and missing items like bananas, yogurt, or house shakes. Several residents reported receiving food that was cold, tasteless, or of poor quality, including bread with mold, mushy vegetables, and melted ice cream. In some cases, residents received food items they specifically disliked or could not consume, such as oatmeal or milk, despite their tray tickets indicating otherwise. Observations and interviews revealed that the discrepancies were due to a combination of staff errors on the tray line, miscommunication between dietary staff and GNAs, and supply shortages or substitutions without resident input. Staff admitted to running out of certain items, such as house shakes and bananas, due to delivery schedules and back orders. Additionally, some staff members were identified as making repeated mistakes and were subsequently removed from the tray line. The dietary manager acknowledged substituting items based on general preferences rather than individual resident requests, such as providing vanilla instead of chocolate frozen nutritional treats. The Nursing Home Administrator confirmed during direct observation that meals served to residents did not match tray tickets and were not visually appealing. Residents expressed dissatisfaction with the quality, temperature, and presentation of their meals, and some reported not receiving alternative items when they voiced concerns. The surveyor documented that these issues persisted even after staff were made aware of the problems, indicating ongoing failures in meal service and communication.
Failure to Maintain Wheelchairs in Sanitary and Comfortable Condition
Penalty
Summary
The facility failed to maintain wheelchairs in a sanitary, comfortable, and well-maintained condition, as evidenced by observations on two of three nursing units. Multiple residents were observed using wheelchairs with cracked or missing vinyl on the armrests, with some armrests missing approximately one inch of vinyl and others showing cracks along the edges and outer surfaces. Residents reported that the wheelchairs had been in this condition for some time, and one resident stated that the wheelchair was given to them in that state. Another resident mentioned that while the armrest had been tightened recently, no replacement was discussed. The Director of Maintenance reported conducting weekly audits of wheelchairs, including checks of brakes, backrests, armrests, wheels, and leg rests. Despite these audits, the deficiencies in wheelchair maintenance were present and observed by surveyors. The Nursing Home Administrator was informed of these concerns following the observations and interviews.
Failure to Timely Report Allegations of Abuse, Neglect, or Injury of Unknown Origin
Penalty
Summary
The facility failed to report allegations of abuse, neglect, or injury of unknown origin to the regulatory agency, the Office of Health Care Quality (OHCQ), within the required 2-hour timeframe for two residents. In one case, a resident was noted to have swelling and dark discoloration on the right thumb, with pain and tenderness, and a staff member observed bruises on both arms but did not immediately report this to the nurse due to her being occupied. The incident, classified as an injury of unknown origin, was not reported to OHCQ on the day it was first observed. In another instance, a visitor alleged that a resident had been inappropriately touched, and the facility became aware of this allegation but did not report it to OHCQ within the mandated 2-hour window. The initial report was sent the following day, outside the required timeframe. Interviews with facility leadership confirmed that both incidents were not reported in a timely manner as required by regulations.
Failure to Thoroughly Investigate Allegations of Abuse
Penalty
Summary
The facility failed to provide documentation that allegations of abuse were thoroughly investigated for three residents during a complaint survey. In one case, an incident was reported in which three staff members allegedly held a resident down while the resident resisted. The facility's investigation included interviews with seven residents but did not include any staff interviews. In another case, a resident with a traumatic subarachnoid hemorrhage, quadriplegia, and contractures was found with facial swelling and discoloration. The investigation included interviews with other residents and three staff members from the day shift, but did not include the GNA who cared for the resident overnight or other staff from previous shifts. In the third case, a resident's visitor reported inappropriate touching. The investigation consisted only of a statement from the ADON and an interview with the resident, who reported feeling uncomfortable but denied being touched. No staff or other resident interviews were conducted for this incident. In each instance, the investigations were incomplete, lacking interviews with all relevant staff or other residents who may have had information about the alleged incidents. The Nursing Home Administrator confirmed during interviews that these investigations were not thorough and stated that she was not employed at the facility at the time the incidents occurred.
Failure to Document Shower Offer and Refusal for Dependent Resident
Penalty
Summary
The facility failed to document that a resident was offered and/or received a shower on their assigned shower days. The resident, who was admitted for rehabilitation following a lumbar vertebra compression fracture and had intermittent confusion requiring extensive assistance with activities of daily living (ADLs), did not have any record of bathing on two specific days and only received bed baths for a subsequent two-week period. There was no documentation indicating that the resident was offered a shower or that a shower was refused, despite the resident being assigned specific shower days. The Director of Nursing confirmed that there was no documentation of showers being offered or refused for this resident.
Failure to Complete and Document Neurological Checks After Resident Falls
Penalty
Summary
The facility failed to ensure that neurological evaluations were comprehensively conducted according to facility policy and procedure after falls for a resident with a history of falls and significant medical conditions, including Alzheimer's disease, muscle weakness, and a cervical fracture. The facility's policy required neurological checks at specific intervals and the inclusion of vital signs with each check following a known or suspected head injury. However, documentation revealed that after two separate falls, neurological checks were not performed or documented at the required intervals, and vital signs were not consistently obtained with each check as required by policy. For one fall, there was a significant delay between the initial and subsequent neurological checks, with vital signs not updated for several hours. In another incident, there was no evidence that neurological checks were performed every 15 minutes as required after the resident was found on the floor with a head injury, and vital signs from previous assessments were reused for multiple checks. Staff interviews confirmed that neurological checks and vital signs were not always completed or documented at the correct times, and that staff sometimes entered data later or failed to update the timing of vital signs. The Director of Nursing and the Administrator both acknowledged that the neurological checks were not completed correctly and that the use of previous vital signs for current assessments was inappropriate. The facility's own staff, including LPNs and a Doctor of Nursing Practice, confirmed that the expected protocol was not followed, and that neurological checks and vital signs should be performed and documented at the required intervals after a fall involving a potential head injury.
Failure to Provide Scheduled Podiatry Care
Penalty
Summary
Facility staff failed to ensure that a resident received podiatry services as ordered. Medical record review showed that the resident, who had a history of significant atherosclerosis and was identified as needing professional foot and nail care to prevent infection or ulceration, was last seen by the podiatrist on 2/4/25. The podiatrist's evaluation indicated a follow-up appointment was scheduled for 4/8/25 for at-risk foot care. However, upon review of facility records and interviews with staff, it was confirmed that the resident was not seen by the podiatrist on the scheduled follow-up date, and there was no documentation of podiatry care provided after the last visit.
Unattended and Unlocked Medication Cart
Penalty
Summary
Facility staff failed to keep a medication cart locked when it was left unattended in the hallway outside a resident's room. During the surveyor's observation, the medication cart was found unlocked and unattended, allowing access to all drawers and medications inside. The unit manager and an agency LPN were present during the observation, with the LPN questioning whether someone had tampered with the cart, but the surveyor confirmed the lock was not engaged prior to opening the drawers. The facility's medication storage policy requires all drugs and biologicals to be stored in locked compartments, with access limited to authorized personnel, but this protocol was not followed in this instance. No specific residents were directly involved or affected at the time of the deficiency, and no additional medical history or resident condition was noted in the report.
Failure to Ensure Timely Outside Specialist Services for Resident with Tracheostomy
Penalty
Summary
Facility staff failed to obtain outside professional services in a timely manner for a resident who was admitted with a tracheostomy. The resident was seen by an ENT specialist, who changed the tracheostomy and scheduled a follow-up appointment with a head and neck surgery specialist. However, the resident did not attend the scheduled specialist appointment, and this failure was confirmed by the facility administrator during an interview. The deficiency was identified during a complaint survey and was based on medical record review and staff interview. The resident's medical record indicated the need for ongoing specialist care related to the tracheostomy, but the facility did not ensure the resident attended the required follow-up appointment as ordered by the ENT specialist.
Failure to Maintain Complete and Accurate Medical Records
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for one resident. Medical record review revealed that the resident, who had been admitted in 2010, did not have documentation of podiatry visits after a specific date, despite having received podiatry care on multiple occasions. During the survey, staff were unable to locate records of podiatry visits that occurred after the last documented date. It was later confirmed through interviews and provision of evaluation forms that several podiatry visits had taken place, but these records had not been uploaded into the resident's medical record due to confusion following a change in medical records staff. The deficiency was identified when the surveyor could not find documentation of the podiatry visits until after intervention.
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.
Illustrative
What surveyors actually found near you
We read the 2,100 citations issued within 25 miles in the last 12 months — including the 15 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 Laurel
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Autumn Lake Healthcare At Cherry Lane | 1.5 mi | ★★★★★ | 20 | 0 |
| Autumn Lake Healthcare At Oak Manor | 3.4 mi | ★★★★★ | 24 | 0 |
| Riderwood Village | 4.4 mi | ★★★★★ | 17 | 0 |
| Autumn Lake Healthcare At Silver Spring | 4.4 mi | ★★★★★ | 15 | 0 |
| Fairland Center | 4.8 mi | ★★★★★ | 4 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Autumn Lake Healthcare At Patuxent River.
100% money-back within 48 hours.
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.