Deficiencies (last 4 years)
Deficiencies (over 4 years)
13.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
8% worse than Maryland average
Maryland average: 12.8 deficiencies/yearDeficiencies per year
24
18
12
6
0
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: May 1, 2025
Visit Reason
The inspection was conducted as a recertification and complaint survey triggered by complaints and concerns regarding the facility's environment, staffing levels, and staff competencies.
Complaint Details
The complaint investigation included resident interviews reporting delayed call light responses, understaffing, and neglect; an anonymous complaint about significant understaffing on a weekend; and staff interviews confirming staffing shortages and lack of AED location knowledge. The complaint was substantiated by observations and interviews.
Findings
The facility failed to maintain a safe environment with an unlocked soiled utility room containing biohazard materials, had insufficient nursing staff to meet resident needs as evidenced by multiple resident and staff interviews and staffing records, and failed to ensure nursing staff were educated on the location of the facility's Automated External Defibrillator (AED).
Deficiencies (3)
Facility failed to maintain a safe environment; soiled utility room unlocked containing biohazard bags, needle containers, and trash.
Facility failed to maintain sufficient nursing staff levels to meet resident needs, resulting in delayed responses and unmet care needs.
Facility staff failed to ensure all nursing staff were educated on the location of the facility's Automated External Defibrillator (AED).
Report Facts
Resident interviews reporting staffing concerns: 6
Complaints reviewed: 11
Staff interviews reporting staffing concerns: 2
Staff interviewed about AED location: 11
Staff unaware of AED location: 3
Resident census on various dates: 34
Resident census on various dates: 37
Resident census on various dates: 62
Resident census on various dates: 39
Resident census on various dates: 63
Resident census on various dates: 29
Resident-to-staff ratio: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #26 | Maintenance Director | Notified about unlocked soiled utility room and attempted to fix the lock |
| Director of Nursing | Director of Nursing (DON) | Acknowledged safety concerns about unlocked soiled utility room and validated staffing concerns |
| Resident #23 | Reported medication delivery delays and staffing shortages | |
| Resident #29 | Reported agency staff did not care about residents | |
| Resident #45 | Reported worst staffing on evening shift | |
| Resident #54 | Reported slow staff response | |
| Resident #55 | Reported delayed call light response and neglect of roommate | |
| Resident #60 | Reported long wait times for assistance | |
| Staff #29 | Staffing Coordinator | Outlined facility staffing goals per unit |
| Geriatric Nursing Aide #21 | Geriatric Nursing Aide | Reported understaffing causing extended work hours and high resident-to-staff ratio |
| Geriatric Nursing Aide #22 | Geriatric Nursing Aide | Reported call-outs and inability to complete tasks timely |
| Staff #23 | Geriatric Nursing Assistant | Did not know AED location |
| Staff #24 | Certified Medication Aide | Initially misidentified AED location |
| Staff #25 | Geriatric Nursing Assistant | Misidentified AED location |
Inspection Report
Complaint Investigation
Deficiencies: 11
Date: May 1, 2025
Visit Reason
The inspection was conducted as a recertification/complaint survey to investigate multiple complaints and assess compliance with regulatory standards.
Complaint Details
The visit was complaint-related, triggered by multiple resident and anonymous complaints regarding staffing shortages, grievance handling, medication administration, dental care delays, and infection control lapses. The complaints were substantiated as evidenced by survey findings.
Findings
The facility was found deficient in multiple areas including failure to maintain a safe environment, inadequate grievance response, insufficient staffing, improper medication administration, failure to provide dental services timely, improper food labeling and storage, and lapses in infection prevention and control practices.
Deficiencies (11)
Failure to maintain a safe environment as evidenced by an unlocked soiled utility room containing biohazard materials.
Failure to provide adequate responses to resident grievances.
Failure to keep residents free from accident hazards, including unlocked Geri chair wheels and fall mat clutter.
Failure to initiate nonpharmacological pain management documentation for a resident receiving pain medication.
Failure to maintain sufficient nursing staff to meet resident needs.
Failure to ensure nurse aides received required training and maintained active licenses.
Failure to ensure narcotics removed from supply were properly documented and administered.
Failure to implement behavior monitoring for residents on antipsychotic medications and failure to ensure medications were given as ordered.
Failure to ensure residents received necessary dental services in a timely manner.
Failure to ensure proper labeling and expiration monitoring of food items in kitchen storage areas.
Failure to implement infection prevention and control program including proper use of PPE for enhanced barrier precautions and maintaining isolation precautions.
Report Facts
Expired hamburger bun packs: 12
Residents affected by staffing concerns: 6
Narcotic documentation discrepancies: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| GNA #31 | Geriatric Nurse Aide | Named in grievance incident involving Resident #55's plant. |
| Maintenance Director (Staff #26) | Notified about unlocked soiled utility room. | |
| Director of Nursing (DON) | Director of Nursing | Interviewed multiple times regarding deficiencies and validated concerns. |
| Nursing Home Administrator (NHA) | Administrator | Interviewed regarding grievance and staffing concerns. |
| Staff #4 | Environmental Services Director | Interviewed about laundry procedures and missing clothing. |
| Staff #18 | Unit Manager | Interviewed about pain management and behavior monitoring. |
| Staff #20 | Certified Nursing Assistant | Found to lack required training and active license. |
| Staff #29 | Staffing Coordinator | Provided staffing goals and records. |
| LPN #16 | Licensed Practical Nurse | Interviewed about narcotic documentation discrepancies and medication administration. |
| LPN #8 | Licensed Practical Nurse | Interviewed about narcotic documentation discrepancies. |
| Staff #27 | Kitchen staff interviewed about expired and unlabeled food items. | |
| Staff #3 | Food Service Director/Certified Dietary Manager | Interviewed about food labeling and expiration concerns. |
| LPN #12 | Licensed Practical Nurse | Observed not wearing gown during enhanced barrier precautions and improper medication handling. |
Inspection Report
Complaint Investigation
Deficiencies: 12
Date: Nov 20, 2024
Visit Reason
The inspection was conducted based on multiple complaints alleging issues including unclean environment, abuse (verbal, sexual, physical), failure to report abuse timely, inadequate investigations, medication errors, and failure to provide appropriate care and notifications.
Complaint Details
The complaint investigation was triggered by multiple complaints alleging unclean environment, abuse (verbal, sexual, physical), failure to report abuse timely, inadequate investigations, medication errors, and failure to provide appropriate care and notifications.
Findings
The facility was found deficient in multiple areas including failure to maintain a clean environment, failure to protect residents from verbal and sexual abuse, failure to timely report abuse allegations, inadequate investigations of abuse incidents, failure to notify resident representatives of transfers, inaccurate assessments, failure to provide appropriate wound care, failure to prevent accidents, failure to develop care plans for trauma, and medication errors resulting in actual harm.
Deficiencies (12)
Facility staff failed to maintain a safe, clean, comfortable and homelike environment on the first floor during a complaint survey.
Facility failed to protect residents from verbal and sexual abuse, affecting 3 residents, including staff verbal abuse and resident-to-resident sexual abuse.
Facility failed to timely report allegations of abuse to the State Survey Agency within required timeframes for 4 residents.
Facility failed to thoroughly investigate 15 of 20 reported incidents involving 14 residents for abuse and 1 resident for injury of unknown origin.
Facility failed to notify resident representative in writing of transfer to hospital for 1 resident.
Facility failed to accurately code resident's status on Minimum Data Set (MDS) assessment for 1 resident.
Facility failed to ensure appropriate wound care and promote healing of a surgical wound for 1 resident.
Facility failed to investigate a fall, determine root cause, and implement interventions to prevent further falls for 1 resident.
Facility failed to provide appropriate interventions for a resident with a history of trauma and abuse.
Facility failed to ensure a resident's medication regimen was free from unnecessary psychotropic medication and failed to limit PRN psychotropic medication orders to 14 days.
Facility failed to ensure residents were free from significant medication errors resulting in actual harm to 1 resident who was administered methadone not prescribed to them, causing hospitalization.
Facility staff obtained a laboratory specimen on a resident without a physician's order.
Report Facts
Residents reviewed for abuse: 15
Residents reviewed for complaints: 20
Residents affected by abuse reporting deficiency: 4
Residents affected by inadequate investigations: 14
Residents affected by medication error: 1
Residents affected by wound care deficiency: 1
Residents affected by fall investigation deficiency: 1
Residents affected by trauma care plan deficiency: 1
Residents affected by psychotropic medication deficiency: 1
Residents affected by notification deficiency: 1
Residents affected by inaccurate MDS coding: 1
Residents affected by laboratory specimen error: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| GNA #31 | Geriatric Nurse Aide | Witnessed sexual abuse incident between residents #37 and #39 |
| Director of Social Work #8 | Director of Social Work | Interviewed residents and reported on abuse cases and trauma care |
| LPN #37 | Licensed Practical Nurse | Involved in verbal abuse allegations and substantiated; removed from care |
| GNA #36 | Geriatric Nursing Assistant | Witnessed verbal abuse incident involving LPN #37 |
| Administrator | Facility Administrator | Interviewed regarding multiple deficiencies including abuse reporting and investigations |
| Former Director of Nursing #16 | Former Director of Nursing | Interviewed regarding abuse investigations and medication error incident |
| Staff #33 | Registered Nurse (Agency) | Administered methadone to wrong resident resulting in hospitalization |
| Staff #16 | Director of Nursing | Led investigation into medication error and corrective actions |
| Staff #8 | Director of Social Work | Reported on resident trauma and abuse history |
| RN #21 | Registered Nurse | Witnessed CMA threatening resident #37 |
| LPN #19 | Licensed Practical Nurse | Interviewed regarding fall incident involving Resident #36 |
| GNA #67 | Geriatric Nursing Assistant | Witnessed fall of Resident #40 and did not notify nurse |
| GNA #68 | Geriatric Nursing Assistant | Witnessed Resident #40 on floor and assisted into wheelchair |
Inspection Report
Annual Inspection
Deficiencies: 23
Date: Jun 14, 2021
Visit Reason
The annual recertification survey was conducted to assess compliance with federal regulations for nursing home care.
Findings
The facility was found deficient in multiple areas including failure to provide written notice for room changes, inadequate housekeeping and maintenance, failure to document transfers and discharges properly, inaccurate resident assessments, incomplete care plans, failure to provide timely pharmacy reviews, inadequate infection control practices, failure to maintain secure handrails, and failure to provide palatable food at safe temperatures.
Deficiencies (23)
Failed to provide a resident and the resident's responsible party with a written notice and reason for a room change before the resident was moved to a different room.
Failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior.
Failed to document that information was provided to the acute care facility when a resident was transferred there emergently.
Failed to notify the resident and/or resident representative in writing of hospital transfers and bed hold policy.
Failed to orient, prepare, and document a resident's preparation for a transfer to the hospital.
Failed to ensure that Minimum Data Set (MDS) assessments were accurately coded.
Failed to ensure that a PASARR was completed for residents as required.
Failed to develop an Activities of Daily Living (ADL) care plan for a resident who required assistance for transport while in a wheelchair.
Failed to develop and initiate a comprehensive, resident-centered care plan specific to the resident's needs.
Failed to review and revise interdisciplinary care plans after MDS assessments and failed to hold care plan meetings with residents or representatives.
Failed to update care plan after an unwitnessed fall and failed to hold interdisciplinary team meetings for care plan review.
Failed to provide activities of daily living (ADL) care to residents who needed assistance, evidenced by long fingernails on a resident.
Failed to provide care and treatment to a resident in accordance with physician's orders, including offloading heels as ordered.
Failed to provide appropriate pressure ulcer care and prevent new ulcers from developing.
Failed to provide appropriate care for residents to maintain and/or improve range of motion (ROM) and mobility.
Failed to post total number and actual hours worked by categories of nursing staff per shift.
Failed to ensure that drug regimen reviews were done monthly, pharmacist recommendations were acted upon timely, and evidence of reviews were maintained.
Failed to provide medically ordered routine dental care to a resident.
Failed to ensure food was served in a palatable manner and at safe temperatures.
Failed to safeguard resident-identifiable information and maintain medical records according to accepted standards.
Failed to provide and implement an infection prevention and control program adhering to guidelines to prevent transmission and spread of germs.
Failed to equip and maintain secure handrails on nursing units.
Failed to provide abuse prevention training to all staff as required.
Report Facts
Residents reviewed: 60
Residents affected: 7
Residents affected: 9
Residents affected: 4
Residents affected: 5
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 2
Residents affected: 1
Staff records reviewed: 5
Staff affected: 1
Inspection Report
Annual Inspection
Deficiencies: 6
Date: Sep 12, 2018
Visit Reason
The inspection was conducted as part of the annual survey process to assess compliance with regulatory requirements for Autumn Lake Healthcare at Alice Manor.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity during bathing, failure to keep medical records confidential, improper labeling and storage of medications, inadequate plumbing preventing contamination of food contact equipment, failure to demonstrate proper hand hygiene during meal service, and improper storage of clean linen exposing it to contamination.
Deficiencies (6)
Failure to maintain dignity for Resident #24 while bathing in the resident's bedroom without privacy curtain.
Failure to keep residents' personal and medical records private and confidential; nursing shift report left exposed on unattended medication cart.
Failure to ensure glucose test strips and medications used for treatments were properly labeled; several opened medications lacked resident names or pharmacy labels.
Failure to install plumbing with air gaps to prevent sewer water contamination in kitchen sinks and dishwasher.
Failure to demonstrate appropriate hand hygiene practices during meal service on the 200 Nursing Unit.
Failure to store linen in an appropriate manner to prevent the spread of infection; clean linen stored openly on third-floor balcony.
Report Facts
Residents investigated: 30
Medication carts inspected: 3
Storage areas inspected: 13
Drain lines without air gaps: 5
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: Some
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff person #10 | Geriatric Nursing Assistant (GNA) | Named in dignity deficiency for bathing Resident #24 without privacy curtain |
| Staff member #1 | Certified Medication Aide (CMA) | Named in confidentiality deficiency for leaving nursing shift report exposed |
| Director of Nursing | Interviewed regarding confidentiality and hand hygiene deficiencies | |
| Administrator | Informed of surveyor's concerns and deficiencies | |
| Geriatric Nursing Assistants #5, #6, #7, #8 | Geriatric Nursing Assistants (GNA) | Observed failing to wash or sanitize hands during meal service |
| Geriatric Nursing Assistant #4 | Geriatric Nursing Assistant (GNA) | Observed failing to wash or sanitize hands during meal service |
| Assistant Director of Nursing (ADON) | Informed and involved in linen storage deficiency | |
| Corporate Nurse | Involved in linen storage deficiency | |
| Staff #9 | Involved in linen storage deficiency |
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