Autumn Lake Healthcare at Calvert Manor

In the surveyor’s words

From the most serious findings on record at Autumn Lake Healthcare at Calvert Manor, in the surveyor’s own words.

• Actual harm, isolatedF689May 26, 2026

  Based on interviews and resident record review, it was determined that the facility failed to prevent an avoidable accident with injury to Resident #15 during a transfer from the wheelchair to the bed. The facility failed to implement interventions, including adequate supervision that was consistent with the resident's needs, care plan and current professional standards of practice to reduce the risk of an accident. As a result, Resident #15 suffered a fall with harm (femur fracture). This was evident for 1 (#15) of 3 residents reviewed for accidents during the recertification survey. The findings include:A sit-to-stand lift is a specialized mobility device designed to help individuals with limited leg strength safely transition from a seated position to a supported, standing posture. […]

• No harm, potential for more than minimal, patternF812May 26, 2026

  Based on observation, facility policy review, and staff interview, it was determined that the facility failed to maintain nutrition room refrigerators in a sanitary manner as evidenced by the facility failing to maintain safe cold-storage temperatures and failing to discard expired resident food. This was found to be evident in 1 (South Unit) of 2 unit nutrition rooms observed. This deficient practice created the potential for foodborne illness.The findings include:On 05/18/2026 at 1:38 PM, the South Unit nourishment room refrigerator was observed. The thermostat inside the refrigerator read 50 F. […]

• No harm, potential for more than minimal, patternF919May 26, 2026

  Based on observations and staff interviews, it was determined that the facility failed to ensure that the residents' call bell system was functioning properly as evidenced by the call bell system monitor being turned off at the nurses' station. This was evident for observations of the North 1 Unit environmental tours during the recertification survey. The findings include: On 05/19/26 at 10:20 AM, the surveyor activated a call bell and observed that there were no audible or visual notifications of the request viewable from the nurses' station. On 05/19/26 at 10:21 AM, LPN #16 was interviewed. She verified that the call bell system monitor by the nurses' station was not on. […]

• No harm, potential for more than minimal, patternF609Apr 2, 2025

  Based on a facility reported incidents, record review, and interviews, it was determined the facility failed to timely report an incident of abuse to the Office of Health Care Quality (OHCQ). This was evident for 6 (#63, #52, #84, #24, #71, #64) of 10 residents reviewed for abuse during the recertification/complaint survey. The findings include: 1) An investigation into Facility Reported Incident (#MD00203162) on 3/26/25 revealed that Resident #63 told a staff person on 3/2/24 at 8:30 AM that a staff person approached them from behind, lifted them up then dropped them to the floor. The staff person who Resident #63 reported the incident to then informed the Director of Nursing (DON) on 3/2/24 at 8:50 AM. […]

• No harm, potential for more than minimal, patternF684Apr 2, 2025

  Based on multiple complaint intakes, record review and staff interviews it was determined that the facility failed to 1) implement an intervention on a resident's care plan, 2) arrange for a resident with fractured arm to go for an orthopedic appointment, 3A/B) fail to timely administer prescribed medications to residents, 4) Promptly report a positive lab result to the physician and hold laxative for a resident with diarrhea. This was evident for 4 (#132, #140, #230 , #142) of 24 complaints reviewed during the recertification/complaint survey. […]