Inspection Report Summary
The most recent inspection on November 13, 2025, identified deficiencies related to medication administration errors and unsecured medication carts. Earlier inspections showed multiple deficiencies involving care planning, nursing competencies, abuse prevention and investigation, and documentation issues, including a substantiated sexual abuse incident and failures in supervision that resulted in actual harm. Inspectors cited recurring themes of medication management problems, incomplete or inadequate care plans, and lapses in staff training and supervision. Complaint investigations were substantiated in some cases, particularly regarding quality of care and abuse allegations, while other complaints were unsubstantiated or not listed. The inspection history indicates ongoing challenges with resident care and medication safety, with no clear pattern of consistent improvement over time.
Deficiencies (last 3 years)
Deficiencies (over 3 years)
23 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
80% worse than Maryland average
Maryland average: 12.8 deficiencies/yearDeficiencies per year
24
18
12
6
0
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Nov 13, 2025
Visit Reason
The inspection was conducted based on a complaint alleging that Resident #1 was not receiving quality care at the facility.
Complaint Details
The complaint investigation was based on Complaint 2662089 alleging poor quality of care for Resident #1, who is totally ventilator dependent and requires full nursing care. The complaint was substantiated by findings of medication administration errors and unsecured medication carts.
Findings
The nursing staff failed to follow physician orders for withholding a cardiovascular medication based on pulse rate and failed to document the pulse rate when administering the medication. Additionally, the staff did not correctly document the route of administration. The facility also failed to maintain medication carts locked and secure during observations on multiple nursing units.
Deficiencies (3)
Failure to follow physician orders for withholding cardiovascular medication when pulse rate was less than 100 and failure to document pulse rate when administering medication.
Failure to correctly document the route of administration of cardiovascular medication.
Failure to maintain medication carts locked and secure on multiple nursing units.
Report Facts
Medication carts unlocked: 5
Medication dose: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed and unaware of medication administration and documentation issues. |
Inspection Report
Annual Inspection
Deficiencies: 15
Date: Jun 13, 2025
Visit Reason
The inspection was conducted as part of the annual survey and complaint investigations to assess compliance with regulatory requirements and investigate specific complaints and incidents reported at Autumn Lake Healthcare at Bridgepark.
Complaint Details
Multiple complaints were investigated including allegations of sexual abuse, failure to notify representatives of medical changes, failure to provide oral care, inadequate physical therapy, and concerns about care planning and supervision. Some complaints were substantiated, such as sexual abuse incidents and failure to provide adequate supervision.
Findings
The facility was found deficient in multiple areas including failure to accommodate resident preferences, failure to notify resident representatives of medical changes, failure to prevent and properly investigate abuse, inadequate care planning and supervision, failure to maintain complete medical records, lack of nursing competencies, failure to provide adequate physical therapy, and failure to provide appropriate activities and nursing care.
Deficiencies (15)
Failed to provide reasonable accommodations of preferences by not honoring a resident's request for female only caregivers.
Failed to notify a resident's representative of a change in the resident's medical condition and transfer to the hospital.
Failed to ensure that a resident remained free of abuse; substantiated sexual abuse incident.
Failed to timely report suspected abuse and injury of unknown origin to the state agency.
Failed to ensure thorough investigation of abuse allegations and provide psychological and physician assessments following substantiated resident to resident sexual abuse.
Failed to provide required documentation or notification related to resident's needs upon transfer.
Failed to develop and implement complete care plans that meet all resident needs, including substance abuse, personal care assistance, and tracheostomy care.
Failed to develop the complete care plan within 7 days of comprehensive assessment and revise care plans by a team of health professionals.
Failed to revise care plans for residents to address incidents and changes in condition, including supervision for inappropriate sexual behavior and fall prevention.
Failed to ensure services provided meet professional standards of quality including labeling of tube feeding containers and timely nursing assessments following change in condition.
Failed to provide care and assistance for activities of daily living, including oral care for a resident with tracheostomy.
Failed to provide adequate supervision to prevent accidents and ensure two-person assistance as required by care plan, resulting in actual harm.
Failed to ensure nurses and nurse aides have appropriate competencies to care for residents.
Failed to provide adequate specialized rehabilitative services, specifically physical therapy as ordered.
Failed to maintain complete and accurate medical records including documentation of wounds, activities, death certificates, and medication administration.
Report Facts
Dates male staff provided care against resident preference: 10
Number of residents reviewed for abuse: 5
Number of residents reviewed for care plans: 6
Number of residents reviewed for tube feedings: 9
Physical therapy sessions received: 8
Number of documented wound care omissions: 30
Number of activity visits logged: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Geriatric Nursing Assistant #18 | Geriatric Nursing Assistant | Witnessed sexual abuse incident involving Resident #11 and Resident #27. |
| Nursing Home Administrator | Administrator | Interviewed regarding multiple deficiencies including failure to update care plans and timely reporting. |
| Director of Nursing | Director of Nursing | Interviewed regarding multiple deficiencies including notification failures, care plan issues, and nursing competencies. |
| Licensed Practical Nurse #20 | Licensed Practical Nurse | Involved in medication administration documentation discrepancy for Resident #104. |
| Registered Nurse #3 | Registered Nurse | Confirmed tube feeding containers were not labeled initially. |
| Staff #14 | Contracted/Agency Registered Nurse | Lack of documented nursing competencies. |
| Staff #29 | Nursing Staff | No tracheostomy care competencies documented. |
| Staff #30 | Nursing Staff | No tracheostomy care competencies documented. |
| Staff #8 | Activities Director | Interviewed regarding activity program and documentation. |
| Staff #19 | Director of Respiratory Therapy | Interviewed regarding responsibility for oral care for dependent residents. |
Inspection Report
Annual Inspection
Deficiencies: 11
Date: Jun 13, 2025
Visit Reason
The annual survey was conducted to assess compliance with regulatory requirements including cleanliness, resident care, and staff competencies.
Findings
The facility was found deficient in multiple areas including cleanliness and privacy issues, incomplete and inadequate care plans, failure to meet professional nursing standards, insufficient activities for residents, improper use of splints, inadequate bowel and bladder care, respiratory care deficiencies, lack of nursing competencies and training, and incomplete resident medical records.
Deficiencies (11)
Facility staff failed to maintain floors and resident shower rooms in a clean and sanitary condition and failed to ensure privacy for male and female residents sharing a joint bathroom.
Facility failed to develop and implement complete care plans addressing all resident needs, including substance abuse and tracheostomy care.
Facility staff failed to ensure tube feeding containers were labeled and failed to follow professional standards in nursing documentation after a resident's change in condition.
Facility failed to provide documented evidence of ongoing activities to support residents' choice of activities.
Facility staff failed to ensure residents wore ordered arm splints to maintain range of motion.
Facility failed to ensure treatment orders for suprapubic catheter and timely changing of residents after incontinence episodes.
Facility staff failed to properly date label oxygen tubing and change water in oxygen humidifier.
Facility failed to ensure nursing staff were competent with required skills and lacked tracheostomy care competencies.
Facility failed to provide nursing staff with minimum required annual cognitive impairment training.
Facility failed to maintain complete and accurate medical records including documentation of injuries, death certificates, wound care, activity logs, and medication administration.
Facility failed to provide nurse aides with required 12 hours of in-service training annually.
Report Facts
Residents reviewed for tube feedings: 9
Residents reviewed for nursing standards: 1
Residents reviewed for activities: 3
Nursing staff evaluated for competency: 5
Nursing staff lacking cognitive impairment training: 5
Nurse aide employee files reviewed: 2
Hours of in-service training required: 12
Date of survey completion: Jun 13, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #13 | Licensed Practical Nurse | Interviewed regarding shower room conditions and care |
| Environmental Services Director #31 | Environmental Services Director | Interviewed regarding cleaning schedules and acknowledged cleanliness issues |
| Director of Nursing | Director of Nursing | Interviewed multiple times regarding care plans, nursing competencies, and training |
| Registered Nurse #3 | Registered Nurse | Confirmed tube feeding labeling issues |
| Physician #35 | Physician | Interviewed regarding resident assessment and admission process |
| Staff #8 | Activities Director | Interviewed regarding resident activities and activity logs |
| Staff #14 | Contracted/Agency Registered Nurse | Lacked nursing competencies |
| Staff #29 | Nursing Staff | Lacked tracheostomy care competencies |
| Staff #30 | Nursing Staff | Lacked tracheostomy care competencies |
| LPN #20 | Licensed Practical Nurse | Inconsistent medication administration documentation |
| Staff #28 | Staff | Confirmed resident should have worn splint |
| Staff #32 | Activities Assistant | Signed off on activities not performed |
Inspection Report
Annual Inspection
Deficiencies: 22
Date: Nov 10, 2021
Visit Reason
The annual survey was conducted to assess compliance with regulatory requirements for nursing home care and services.
Findings
The facility was found deficient in multiple areas including failure to obtain proper consents, failure to notify physicians and family members of significant clinical findings, failure to post survey results, failure to maintain confidentiality of resident information, failure to provide timely beneficiary notices, failure to notify residents and responsible parties of hospital transfers and bed hold policies, inaccurate resident assessments and care plans, medication administration errors, failure to provide ordered treatments and consultations, failure to maintain accurate medical records, infection control lapses, and unsafe equipment maintenance.
Deficiencies (22)
Failure to obtain responsible party consent for flu vaccine and failure to have a representative present when residents signed documents.
Failure to post signage to alert residents and visitors of the location of survey results.
Failure to notify resident's physician and family member of chest x-ray results indicating pneumonia.
Failure to provide proper beneficiary notices regarding Medicare coverage at discharge.
Failure to maintain confidentiality of resident medical information on computer screens.
Failure to provide timely notification of hospital transfers to residents and responsible parties.
Failure to provide residents and/or their representatives with the facility's bed hold policy at transfer.
Failure to ensure accuracy of facility assessments, including incorrect documentation of catheter use.
Failure to review and revise care plans to reflect current and accurate interventions, failure to hold care plan meetings timely, and lack of interdisciplinary care planning documentation.
Failure to administer medications within 1-hour time frame as ordered.
Failure to implement ongoing resident-centered activities program for a resident.
Failure to provide needed care including medication administration, heel floating, and obtaining ordered consultations.
Failure to provide appropriate pressure ulcer care and prevent new ulcers from developing.
Failure to provide fall mats as ordered to prevent falls.
Failure to provide prescribed diet, failure to weigh resident timely, failure to withhold straw as ordered, and failure to monitor significant weight loss.
Failure to provide safe, appropriate dialysis care including incomplete dialysis communication forms and failure to obtain post dialysis weights and vital signs.
Failure to ensure monthly medication regimen reviews by consultant pharmacist and failure to act on pharmacist recommendations.
Failure to properly store medications and treatment supplies in locked compartments accessible only to authorized staff.
Failure to conduct and document an accurate, up-to-date facility-wide assessment annually.
Failure to maintain accurate medical records including failure to remove former resident documents and failure to maintain documentation supporting surrogate decision making.
Failure to implement infection prevention and control program including failure of staff to wear face masks and improper handling of dirty linens.
Failure to maintain kitchen equipment in safe operating condition including non-operational hot water faucet and peeling paint.
Report Facts
Residents selected for review: 52
Medication administration error rate: 10.26
Weight loss: 10.2
Weight loss percentage: 8.3
Residents reviewed for hospitalizations: 6
Residents with failure to notify transfer: 3
Residents with failure to provide bed hold policy: 3
Residents reviewed for unnecessary medication: 5
Residents reviewed for pain: 2
Residents reviewed for dialysis: 1
Residents reviewed for medication errors: 7
Residents reviewed for infection control: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee #15 | Witnessed Resident #285 sign a document to pay the facility from personal funds | |
| Staff #18 | Interviewed regarding failure to post survey results and medication administration outside parameters | |
| Staff #36 | Housekeeper | Observed not wearing face mask while working in facility |
| Staff #31 | Facility Porter | Observed not wearing face mask while working in facility |
| Staff #32 | Observed with face mask pulled under chin not covering mouth and nose | |
| Staff #12 | Unit Manager | Informed of observation of resident medical information visible on computer screen |
| Staff #17 | Revealed medication refill process for Resident #9 | |
| Staff #16 | Observed medication administration errors for Residents #33 and #13 | |
| Nursing Home Administrator | Interviewed regarding multiple deficiencies and notified of concerns | |
| Chief Clinical Officer | Interviewed regarding multiple deficiencies and notified of concerns | |
| Director of Nursing | Interviewed regarding medication administration errors and failure to act on pharmacist recommendations | |
| Consultant Pharmacist | Interviewed regarding failure to enter pharmacy reviews and medication recommendations | |
| Assistant Director of Nursing | Interviewed regarding hospital transfer notifications and dental consults | |
| Regional Dietitian | Interviewed regarding failure to reweigh Resident #77 after weight loss | |
| Social Service Director | Interviewed regarding care plan meeting attendance | |
| Activities Director | Interviewed regarding resident activities access and requests | |
| Vice President of Clinical Services | Interviewed regarding facility assessment and failure to obtain podiatry consultation |
Inspection Report
Annual Inspection
Deficiencies: 18
Date: Nov 29, 2018
Visit Reason
The inspection was an annual recertification survey to assess compliance with regulatory requirements across multiple areas including resident rights, personal funds management, abuse reporting, transfers and discharges, care planning, medication administration, vision and hearing services, mobility and rehabilitation, medication regimen appropriateness, infection control, and facility environment.
Findings
The facility was found deficient in multiple areas including failure to honor resident self-determination regarding laboratory testing, inadequate accounting of resident personal funds, delayed reporting of abuse allegations, failure to notify ombudsman of resident transfers, failure to implement care plans for smoking and mobility, improper medication preparation, failure to obtain vision and dental consults, failure to monitor psychotropic medication use and behaviors, unlocked medication and treatment carts, expired and unlabeled food items in the kitchen, failure to reassess wheelchair fit, incomplete hospice documentation, and inadequate infection control monitoring.
Deficiencies (18)
Failed to follow a resident's wishes to obtain a laboratory test.
Failed to maintain a system ensuring full and complete accounting of a resident's personal monies.
Failed to immediately report an allegation of abuse to the facility administrator.
Failed to provide timely notification to resident, representative, and ombudsman before transfer or discharge.
Failed to implement a care plan for a resident who smokes.
Failed to follow standards of practice regarding medication preparation.
Failed to obtain an eye consultation for a resident with poor vision.
Failed to provide appropriate care to maintain or improve range of motion and mobility by not applying splints as ordered.
Failed to ensure resident's drug regimen was free from unnecessary drugs due to lack of adequate indication for psychotropic medication.
Failed to monitor and record behaviors routinely for residents receiving psychotropic medications.
Failed to ensure treatment and medication carts were locked and secured.
Failed to obtain dental services for a resident.
Failed to discard expired food, label and date food properly, and maintain a clean kitchen environment.
Failed to evaluate and reassess a resident's wheelchair fit and comfort.
Failed to maintain accurate medical records by not including hospice documentation.
Failed to track and monitor a resident with an infection upon admission.
Failed to keep the air intake unit in the main kitchen clean and in safe operating condition.
Failed to identify a resident as a smoker, assess for safe smoking, implement a care plan, and update the facility list of smokers.
Report Facts
Residents reviewed for choices: 4
Residents reviewed for personal property: 1
Residents reviewed for abuse: 4
Residents reviewed for facility-initiated transfer: 46
Residents reviewed for smoking: 2
Residents reviewed for unnecessary medications: 5
Residents reviewed for hospice services: 2
Residents reviewed for infections: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee #4 | Named in finding regarding failure to follow resident #82's wishes regarding laboratory samples | |
| Employee #21 | Named in finding regarding resident #55's personal money management | |
| Employee #19 | Witnessed abuse incident involving Resident #195 and delayed reporting | |
| Employee #13 | Interviewed regarding Resident #89 smoking behavior | |
| Employee #18 | Interviewed regarding Resident #89 smoking behavior | |
| Employee #10 | Observed pouring excess medication back into bottle during medication pass for Resident #67 | |
| Employee #7 | Interviewed regarding Resident #89's psychiatric assessment and dental consult | |
| Employee #14 | Confirmed failure to apply splints and boots as ordered for Residents #18 and #39 | |
| Employee #8 | Unaware of physician order for knee braces for Resident #36 | |
| Employee #15 | Observed with unlocked medication cart near Resident #43 | |
| Employee #16 | Observed Resident #6 sitting low in wheelchair and arms hitting backrest poles | |
| Employee #17 | Reported no follow-up wheelchair assessment for Resident #6 since initial fitting |
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