Average — CMS composite of the measures below.
The next survey window likely opens around October 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 Post-acute Care Center during CMS and state inspections, most recent first.
A resident with DM, dementia, and CKD developed a ruptured fluid blister to the left heel, and the provider recommended wound cleansing, daily Medihoney, and heel elevation. The TAR did not show the ordered wound treatment for two days, and the DON stated that nursing staff are expected to enter physician orders when received, not two days later.
Surveyors found that a discharged resident’s closed medical record folder, supplied by the Director of Medical Records at the request of a nurse surveyor, contained multiple documents belonging to another resident, demonstrating inaccurate and incomplete record maintenance. The resident had recently been admitted following a hospital stay for cardiac symptoms and later discharged, yet the Director of Medical Records reported that the record was not officially closed because it was not placed in the designated red folder. The report emphasizes that accurate documentation is integral to medication administration and that inaccurate medication documentation can place residents at significant risk of medication error and provide incomplete or inaccurate information for providers and caregivers.
A facility failed to follow professional standards for enteral feeding and medication administration for multiple residents. A tube feeding was left hanging at the bedside without labeling or a documented start time or rate, one resident’s scheduled meds were given many hours late, another resident received methadone in a way that did not match the ordered dose and custody records and had BP hold parameters ignored on multiple occasions, and a medication cup with lactulose was left unattended at the bedside before the ordered time.
Unsafe and Unsanitary Facility Conditions: Surveyors found the facility dirty, poorly maintained, and lacking enough clean linen for residents. Observations included foul odors, stained walls and floors, dirty hallway railings, scratched resident room doors, missing and mismatched linoleum, peeling paint, and clutter in the clean utility room. Staff also stated there were not enough blankets for all residents, and only 2 blankets were seen on the clean linen cart after distribution.
A resident’s care plan continued to list anticoagulant therapy even though the resident had no current anticoagulant orders and the last Heparin order had been discontinued. The MDS Section N correctly changed from indicating anticoagulant use to "No" on later assessments, but the care plan was not revised to match those changes. During interview, the MDS Coordinator said the unit manager was responsible for care plan updates, and the Unit Manager agreed the care plan did not accurately reflect the resident’s current anticoagulant status.
A resident received methadone at an excessive dose because staff gave a full bottle instead of splitting the dose as intended. The wife reported the resident appeared drowsy and sedated, and the chart also showed falls during the period of the dosing error. MAR and chain-of-custody records reflected inconsistent documentation of the methadone supply and administration.
A resident receiving methadone for opioid disorder was given an incorrect dose because nurses administered a whole bottle instead of splitting the dose as intended. The resident’s wife reported he appeared drowsy and sedated, and the methadone program later denied an early refill because the medication had been used too soon. Record review showed the resident received 102 mg BID for an extended period due to the dosing error.
Incomplete and inaccurate documentation was found for three residents. One resident’s methadone records were inconsistent, with staff giving the wrong dose from bottles containing split doses and the chart showing administration that did not match the amount received; the resident was also reported to appear sedated. For two other residents, CMS beneficiary notice forms incorrectly stated discharge to the hospital even though the chart documented discharge home with family and home health services.
Failure to Maintain Resident Dignity During Meals and Incontinence Care: Staff were observed feeding residents while standing instead of seated, leaving one resident to eat by bringing the mouth close to the plate until utensils were provided, and failing to promptly address a resident’s soiled room and pad with dried brown matter present. The DON, NHA, unit manager, and GNAs were made aware of the observations.
A facility failed to maintain a safe, clean, comfortable, and homelike environment in three resident rooms on one unit. Surveyors observed dirty linoleum floors with built-up wax, a damaged door, a rusty toilet bolt, black marks in a toilet, and a broken bedside cabinet drawer. The housekeeping director stated there was no schedule for stripping and waxing floors and did not provide documentation for monthly deep cleaning or room repairs.
Outdated activity calendars were observed in multiple resident rooms, including a resident on the vent unit with intact cognition. The facility also did not show that a dependent resident received activities matching family-requested preferences, and the activity records for weekly musical encounters did not identify which resident participated, when the activity occurred, or the resident’s response.
A resident with Marfan Syndrome and anoxic brain damage rolled out of bed while being cleaned by a GNA. The resident’s care plan identified a high fall risk related to paralysis, immobility, and spontaneous autonomic movement, and required two-person assistance for transfers and repositioning. The DON confirmed the GNA provided care alone and that the resident was pulled during repositioning before rolling onto the floor.
Unsafe PEG tube feeding practices were observed for multiple residents. A resident’s feeding bottle was left unlabeled with no infusion rate or hang time, another resident’s tube feed remained hanging with inconsistent labeling and pump readings, and a third resident stayed connected to the tubing after the feed was reportedly complete, with the pump later showing the infusion had not finished. Staff responses showed inconsistent handling of tube feeds and disconnect timing.
Missing Ambu Bags at Bedside for Residents With Tracheostomy Tubes: The facility failed to provide respiratory care consistent with professional standards for four residents with tracheostomy tubes. Surveyors observed that a manual resuscitator/bag valve mask was not present in the rooms of two residents, and an RT confirmed the devices were not there. Two additional residents with tracheostomy tubes and oxygen in use also did not have an Ambu bag observed or located at bedside during unit checks, and an LPN Unit Manager confirmed the bags were not present.
Unsanitary Kitchen Conditions: Surveyors observed a large pile of dark black substance under a shelf in the walk-in freezer, dried food residue in a lid holder tray, chipping paint on a kitchen post, standing water near the dishwasher, and ice cubes scattered across the kitchen floor. The CDM stated the area should be cleaned each day and acknowledged the conditions should not have been present, and the unsanitary conditions remained unaddressed during follow-up observations.
Infection control practices were not followed in several areas of the facility. A resident was found with a soiled room and bedding, a GNA fed a resident while a wig/hair unit sat on the dining table next to food, laundry carts were uncovered with worn covers and an open washroom door, a clean linen bin was placed in a resident bathroom, and a resident’s urinary catheter bag was observed on the floor.
A resident's family alleged neglect after the resident fell and fractured a leg. The facility's investigation was found to be inadequate as it did not include interviews with other residents to disprove widespread staff negligence. The DON confirmed the investigation's shortcomings.
Delayed Implementation of Wound Care Orders
Penalty
Summary
The facility failed to ensure physician orders and provider recommendations were implemented timely after a change in condition for Resident #6, who was admitted with diagnoses including diabetes mellitus, dementia, and chronic kidney disease. On 02/08/2026, the resident developed a ruptured fluid blister to the left heel, and the provider recommended cleansing the heel with wound cleanser, applying Medihoney daily, and elevating the heel with a pillow. Review of the February 2026 TAR showed no evidence that the ordered left heel wound treatment was provided on 02/09/2026 or 02/10/2026, and the wound treatment order did not appear on the TAR until 02/11/2026. During interview, the DON stated that when nursing staff enter physician orders, the expectation is that orders are entered at the time they are received and not two days later.
Incomplete and Misfiled Closed Medical Record for a Discharged Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate clinical records for a resident in accordance with accepted professional standards. During a complaint survey, a nurse surveyor requested all closed paper documents and electronic medical record access for Resident #1, who had been admitted after a hospital stay for cardiac symptoms and later discharged from the facility. The Director of Medical Records provided a folder identified as the closed medical record for Resident #1. Upon review, the surveyor found that several documents in this folder actually belonged to another resident (Resident #3), indicating that the resident’s closed record was not accurately compiled. In an interview, the Director of Medical Records stated that the contents of Resident #1’s closed record folder were what had been received from the nursing unit and also acknowledged that Resident #1’s record had not been officially deemed closed because the documents were not in a red folder. The report notes that documentation is an integral part of medication administration and that inaccurate medication documentation can place residents at significant risk of medication error and provide incomplete or inaccurate information for providers and caregivers. The findings show that the facility did not have a system in place to ensure that clinical records, including medication documentation, were complete and accurately maintained for this resident.
Failure to Follow Medication and Feeding Standards
Penalty
Summary
The facility failed to meet professional standards of quality of care related to enteral feeding and medication administration for four residents. During observation rounds, one resident’s tube feeding bottle was found hanging at the bedside without a label, without a documented start time or infusion rate, and with the feeding not running while the tubing remained connected to the PEG site. Staff were unable to state when the feeding had been started or what rate was intended, and the facility policy required feeding tubes to be used in accordance with current clinical standards of practice. Medication administration concerns were also identified for another resident whose morning medications were scheduled for 6:00 AM but were administered at 1:21 PM. The resident’s record showed late administration of hydralazine HCl 100 mg for hypertension and gabapentin 600 mg for burning in both lower extremities. When interviewed, staff stated the expectation was to administer medications within one hour before or after the scheduled time. A third resident received methadone in a manner that did not match the ordered dosing and custody documentation. The resident’s wife reported the resident had been double-dosed for 14 days and appeared drowsy and sedated. Review of records showed methadone orders were transcribed and administered in a way that resulted in the resident receiving 102 mg twice daily from 11/21/24 to 12/4/24, while the chain of custody and refill timing did not align with the amount of medication received. The record also showed the ordered blood pressure hold parameter of systolic BP less than 110 was not followed on multiple dates, with no documentation that the medication was held or that the provider was notified. For another resident, a medication cup containing lactulose was observed left at the bedside before the scheduled administration time. The resident could not identify the medication or its purpose, and the CMA stated the resident did not take all medications at once and that she returned periodically until the resident took them all. The MAR showed lactulose was ordered for 10:00 AM, yet the medication was observed unattended at the bedside nearly two hours before the ordered time and was not charted as given at the time of observation.
Unsafe and Unsanitary Facility Conditions
Penalty
Summary
The facility failed to ensure a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. Complaint intakes alleged the facility was outdated, smelled foul, and was dirty, and a family member stated the facility was dirty and nasty and needed to do better with cleaning and caring for residents. Survey observations found the facility was not well-lit, hallway walls, baseboards, and railings were dirty with old stains and spots, and some hallway areas smelled of urine. The surveyor also observed that some resident rooms did not have chairs for visitors, and the wall behind Resident #11's bed was stained with a substance that appeared to have been there for some time. Additional observations noted dirty marks around the whiteboard at the nurse's station and heavy scratches on resident room doors. The facility also failed to provide enough clean linen to all residents and failed to maintain certain environmental areas and fixtures. Staff stated there were not enough blankets for all residents and that more were being ordered, and after clean linen was distributed, only 2 blankets were observed on the clean linen cart in the laundry room. Surveyors observed rust-like stained linoleum, mismatched flooring pieces, and missing linoleum near the third-floor clinical unit nursing station, as well as peeling paint on hallway hand railings between rooms. In the clean utility room, surveyors observed a red biohazard bag inside a cardboard box on the floor, dirty linen uncovered with personal resident clothing items, no paper towels in the towel container near the sink, oxygen tanks in holders on the wall, and an old call bell and cord lying on the floor. The housekeeping director stated there was no schedule for stripping and waxing the linoleum floors and that monthly deep cleaning of resident rooms was performed without documentation provided to support it.
Care Plan Not Updated to Match MDS Anticoagulant Status
Penalty
Summary
The facility failed to review and revise the care plan after each MDS assessment for a resident receiving dialysis-related review. Resident #32’s care plan, dated 9/11/25, identified anticoagulant therapy related to a cardiac disease process, with the last revision noted on 9/15/25. However, record review showed there were no current anticoagulant therapy orders in place, and the resident’s last anticoagulant, Heparin, had been ordered on 10/15/24 and discontinued on 2/4/25. The care plan was not updated to reflect that the anticoagulant therapy had ended. The resident’s MDS Section N entries showed the medication status had changed over time: it indicated anticoagulant therapy was being received on the 9/13/24 annual and 12/14/24 quarterly assessments, then reflected "No" for anticoagulant therapy on the 3/16/25 quarterly, 6/16/25 quarterly, and 9/14/25 annual assessments after Heparin was discontinued. During interview, the MDS Coordinator stated the unit manager was responsible for updating the care plan with changes, and the Unit Manager stated medication orders were run every 24 hours and care plan discussions and updates were done weekly. When asked whether the care plan accurately reflected the current anticoagulant therapy status, the Unit Manager agreed that it did not.
Excess Methadone Dosing and Medication Administration Error
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs when methadone was administered at an excessive dosage for an extended period. The resident's wife reported that he was double-dosed for 14 days and appeared very drowsy and sedated during visits. She also stated that she had asked nurses several times why he looked sedated but did not receive a response. The resident was receiving methadone for opioid disorder/substance abuse, and the record showed an initial order that was later discontinued and replaced with another methadone order. The DON later explained that the methadone had arrived in bottles containing two doses each, but staff were accustomed to single-dose bottles and gave a whole bottle as the dose instead of splitting it in half. Record review showed that from 11/21/24 through 12/4/24, the resident received 102 mg of methadone twice daily. The facility did not identify the dosing problem until a refill request was denied as being too soon. The resident's chart also documented falls on 11/21/24 and 11/23/24, but the progress notes did not describe the resident's condition or explain why the falls occurred. The grievance filed by the resident's wife stated that he had been receiving too much methadone over the prior 2 weeks, and the chain of custody and MAR documentation showed inconsistencies in the amount received and documented administration of the medication.
Significant Methadone Dosing Error
Penalty
Summary
A resident receiving methadone for opioid disorder/substance abuse was found to have received an incorrect dosage for an extended period. The resident’s wife reported that he appeared very drowsy and sedated, and she said she had asked nurses several times why he looked that way but did not receive a response. She also reported that the methadone program denied an early refill because the medication had been used too soon after the prior supply. Record review showed the resident’s methadone order was transcribed as 25 mL twice daily, then later as 10 mL twice daily, with the medication intended to continue through 12/16/24. However, the facility received 14 bottles for the period from 11/20/24 to 12/16/24, and the chain of custody record stated there were 102 mg in each bottle with 14 bottles received. The DON stated the nurses were accustomed to single-dose bottles and gave a whole bottle as the dose instead of splitting it in half, resulting in the resident receiving 102 mg twice daily from 11/21/24 through 12/4/24. The grievance review stated no negative outcomes or adverse reactions were identified.
Incomplete and Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to ensure that medical records and forms were complete and accurately documented for three residents. For one resident, staff and family reported that the resident was given methadone incorrectly and appeared drowsy and sedated. The wife stated she had asked nurses several times why the resident looked sedated but received no response. The DON later explained that the methadone had come from the program in bottles containing two doses, but nurses were used to single-dose bottles and gave a whole bottle as the dose instead of splitting it in half. Record review showed inconsistencies in the methadone documentation. The Licensed Nurse Administration Record reflected methadone orders that were transcribed and discontinued on the same day, then restarted with a different order. The record showed no missed doses over a period when the facility had only received 14 bottles for use, which would not have been enough to cover the documented administration period. The Chain of Custody Record stated the facility received 28 doses in 14 bottles and documented one dose a day, but the resident only signed off on receipt through part of the period, with the remainder documented only by the nurse. The next chain of custody record did not occur until the end of the month, when the dosing was split into separate AM and PM bottles. For two other residents, the facility completed SNF Beneficiary Protection Notification Review forms that stated the residents were discharged to the hospital, but the medical record and the facility’s own discharge documentation showed they were discharged home. For one resident, the chart contained discharge notes stating the resident was discharged home with spouse care and home health services. For the other resident, the chart contained discharge notes stating the resident was discharged home with family transport and home health services. When questioned, the NHA stated the MDS Coordinator likely entered the wrong discharge information, but later stated there was no other information and that the residents were discharged home.
Failure to Maintain Resident Dignity During Meals and Incontinence Care
Penalty
Summary
The facility failed to ensure residents’ rights to a dignified existence during meals. On the third-floor dementia unit, meal service records showed lunch delivery times for residents needing assistance, and staff reported that clinical staff take turns feeding and monitoring residents in the dining room while a hospitality aide usually helps with fluids. During observation, the surveyor saw a GNA feeding Resident #4 while standing, and later observed another GNA standing while spoon-feeding Resident #188 because no empty chair was available. The unit manager and GNAs acknowledged that staff are expected to be seated when feeding residents. The facility also failed to maintain dignity during incontinence care and room cleanliness for Resident #31. During an initial tour, the resident’s room had an odor, and a very large dried brown area was observed on the floor underneath and beside the bed. The resident was present in the room and stated that medication had been given to help with toileting, but the resident was unable to feel or know if it worked. When the nurse entered the room, the dried brown area on the floor was confirmed, and the resident’s pad was found to have a large brown dried area with brown edges. The nurse stated that someone would assist with changing the resident. The facility also failed to provide dignified mealtime assistance for Resident #58. During a lunch dining observation on the second floor, a dietary staff member placed a plate of food in front of the resident and continued serving other residents. Resident #58 was observed bent over with the face very close to the plate, using the mouth to retrieve food from the plate. After the nurse was alerted, a GNA retrieved utensils and placed them in the resident’s hand, after which the resident began eating with the utensils and cuing from the GNA.
Unclean and Damaged Resident Rooms
Penalty
Summary
The facility failed to ensure residents were provided with a safe, clean, comfortable, and homelike environment in three resident rooms on one unit. During observation rounds, rooms 312, 309, and 316 were found with dirty linoleum floors and built-up wax; room 312 also had a deep gouge with missing wood on the door, a rusty bolt on the toilet, and black marks or stains inside the toilet. Room 316 had a broken bedside cabinet drawer with a broken handle. When interviewed, the housekeeping director stated there was no schedule for stripping and waxing the facility’s linoleum floors and said the facility performed monthly deep cleaning of resident rooms, but no documentation was provided to support that statement. The director also stated the facility used the TELS system to document and report environmental issues, but prior to the exit conference no documentation of repairs or cleaning for the third-floor rooms was provided.
Outdated activity calendars and incomplete activity documentation
Penalty
Summary
The facility failed to maintain up-to-date activity calendars in residents’ rooms for Resident #6, Resident #101, and Resident #1. During multiple observations on 11/18/2025, 11/19/2025, and 11/20/2025, the surveyor found that Resident #6’s room displayed an activities calendar from September 2025 and Resident #101’s room displayed a calendar from October 2025. Resident #1, who was observed in bed on the vent unit and had a Brief Interview for Mental Status score of 15 indicating intact cognition, also had an outdated October 2025 activity calendar posted in the room during observations on 11/18/2025, 11/19/2025, and 11/20/2025. The facility also failed to ensure that activities addressed the specific preferences and stimulation requested for a dependent resident, and failed to demonstrate consistent activity services were provided and documented. For Resident #1, the administrator provided copies of once-per-week musical encounters during visits with vent residents, but the documentation did not identify which specific resident received the musical experience on a specific date and time or the resident’s response to the activity. The concerns regarding activities were reviewed prior to and during the exit conference.
Failure to Provide Required Two-Person Assistance During Bed Care
Penalty
Summary
The facility failed to ensure that a resident received appropriate supervision during care when the resident rolled out of bed while being cleaned. The resident had diagnoses including Marfan Syndrome and anoxic brain damage, and the medical record showed a fall on 8/22/25. The facility’s fall investigation stated that the assigned GNA reported the resident rolled out of bed while she was cleaning the resident, and the resident was assessed with no injuries. The resident’s fall care plan identified the resident as having had an actual fall and being at high risk for falls related to paralysis and immobility with spontaneous autonomic movement. The care plan, initiated 5/25/20, included interventions for two-person assistance with transfers and repositioning per MDS/care plan. During interview, the DON explained that the GNA pulled the resident toward her to reposition the resident to wipe the resident’s back, then went to the other side and pulled the resident again, at which point the resident rolled onto the floor. The DON confirmed that the GNA provided care alone and that the resident required two staff for bed transfers and repositioning.
Unsafe PEG Tube Feeding Practices
Penalty
Summary
Safe enteral feeding practices were not followed for residents receiving PEG tube feedings. During observation rounds, a resident’s tube feeding bottle was found hanging at the bedside without a label showing the rate of infusion or the time it had been hung, and the feeding was not running while the tubing remained connected to the resident’s PEG site. Staff was unable to provide the start time or intended rate, and the facility policy required feeding tubes to be used in accordance with current clinical standards of practice to prevent complications. For another resident, a NEPRO with CARBSTEADY tube feed bottle was observed hanging at the bedside with a label stating it had been hung at 2:00 a.m., while the Kangaroo OMNI pump showed the feeding was in progress at 50 mL/hr. Follow-up observations later showed the same bottle still hanging with large amounts of fluid remaining, despite the label and pump settings indicating that much more should have infused by that time. Staff stated that all tube feeds were held from 9 a.m. to 1 p.m., and the resident’s orders directed enteral feeding at 50 mL/hr for 20 hours per day. For a third resident, the tube feeding bottle was observed with approximately 350 mL remaining and a label that listed the hang date but left the start time blank. The resident remained connected to the tubing even though staff stated the feeding had been completed earlier and that the line was usually disconnected only when medications were given. When the pump was turned back on, it displayed that the feed had not been completed and that 530 mL remained. The resident’s orders directed Jevity 1.5 via PEG at 75 mL/hr for 20 hours per day, with the feed to be down at 9 a.m. or when total volume was infused.
Missing Ambu Bags at Bedside for Residents With Tracheostomy Tubes
Penalty
Summary
The facility failed to ensure that respiratory care, including tracheostomy care and tracheal suctioning, was provided consistent with professional standards of practice for 4 residents with tracheostomy tubes. During observation rounds, a manual resuscitator or bag valve mask was not observed in the rooms of two residents with tracheostomy tubes, including one resident whose room was checked at 7:38 AM and another at 7:40 AM. When the Respiratory Therapist was asked to locate the device in each room, the therapist searched and stated that the manual resuscitator or bag valve mask was not present in either room. Additional observations on the Terrace Unit found two more residents with tracheostomy tubes and oxygen in use who did not have a manual resuscitator/Ambu bag observed or located at bedside during initial and follow-up checks. A unit walk-through with the LPN Unit Manager confirmed that no bags were at the bedside for these residents. The report states that the bags were obtained from the Vent Unit after the surveyor raised the concern, and a later follow-up observation showed the bags at the bedsides of both residents.
Unsanitary Kitchen Conditions
Penalty
Summary
The facility failed to maintain the kitchen in a sanitary manner to prevent the potential for food contamination. During observation, surveyors noted a large pile of dark black substance on the floor under a shelf inside the walk-in freezer, a lid holder tray with dried food residue, chipping paint on a post within the kitchen, standing water on the floor near the dishwasher, and ten ice cubes spaced out across the kitchen floor. These unsanitary conditions were still present during follow-up observations on two later dates. During interview, the Certified Dietary Manager stated that the area should be cleaned each day and acknowledged that the observed conditions should not have been present.
Infection Control Lapses in Resident Care, Dining, Laundry, and Catheter Handling
Penalty
Summary
The facility failed to adhere to infection control practices and guidelines to prevent the spread of germs and cross contamination in multiple observed situations. During an initial tour, Resident #31 was found in a room with an odor present, a very large dried brown area on the floor beneath and beside the bed, and a resident pad with a large brown area and dried brown edges. The resident stated that medication had been given to help with toileting but that the resident was unable to feel or know if it worked. The nurse confirmed the dried brown area on the floor and on the pad, and the resident was later observed in the hallway while the room remained uncleaned for a period of time. During a lunch dining observation, a GNA was feeding Resident #73 while the resident sat at a table with another resident whose family member was feeding them. A wig or hair unit was lying on the table next to Resident #73's food while the GNA continued feeding the resident. The surveyor alerted the nurse, who then spoke with the family member, and the hair item was removed from the table. Additional infection control concerns were observed in the laundry and resident care areas. In the laundry area, the washroom entrance door needed repair and would not fully close, the clean linen area next to the washroom was open, linen carts were uncovered, and several cart covers were worn and had open areas, with one cart having a large open area at the top. In another observation, a clean linen bin was found inside a resident bathroom with the door closed and was removed to the clean utility room. Also, Resident #26's urinary catheter bag was observed lying on the floor in a dignity bag, and staff stated the bag should not have been on the floor; the facility policy and staff interview indicated the expectation was to keep the catheter bag off the floor.
Inadequate Investigation of Neglect Allegation
Penalty
Summary
The facility staff failed to thoroughly investigate a complaint of neglect involving a resident who fell and sustained a fractured leg. The incident occurred when the resident's family alleged neglect after the fall on the unit. Upon review, it was found that the facility's investigation into the incident was inadequate, as it did not include interviews with other residents to disprove widespread negligence by the staff. The Director of Nursing confirmed that the investigation lacked these critical interviews, indicating a deficiency in the facility's response to the allegation of neglect.
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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.
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Nursing homes near Baltimore
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Autumn Lake Healthcare At Overlea | 1.4 mi | ★★★★★ | 5 | 0 |
| Future Care Cold Spring | 1.8 mi | ★★★★★ | 29 | 0 |
| Good Samaritan Nursing Home Operator, Llc | 3 mi | ★★★★★ | 4 | 0 |
| Rossville Rehabilitation And Healthcare Center | 3.2 mi | ★★★★★ | 33 | 1 |
| The Nursing And Rehab Center At Stadium Place | 3.2 mi | ★★★★★ | 8 | 0 |
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