Autumn Lake Healthcare at Patuxent River

In the surveyor’s words

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

• Actual harm, isolatedF697May 6, 2022

  Based on medical record review and interview with facility staff, it was determined that a resident with a noted change in condition and documented pain for a fracture, was not medicated with ordered pain medication or hospitalized timely. This was evident for 1 of 1 Resident (#119) reviewed during the investigative portion of the survey. The findings include: Review of the medical record for Resident #119 on 4/25/2022 at 9:31 AM revealed admission on 4/30/2021 including nondisplaced intertrochanteric fracture of the left femur admitted for routine healing and with a documented history of falling. Further review revealed that Resident #119 had 6 falls during his/her stay in the facility with the 6th fall occurring on 1/19/2022. […]

• No harm, potential for more than minimal, widespreadF838Oct 19, 2021

  Based on review of facility records and an interview with staff, it was determined the facility failed to revise and document an accurate up-to-date facility-wide assessment. This was identified during the review of the facility emergency preparedness plan during an infection control survey and complaint survey. This has the potential to affect all residents within the facility. The findings include: A facility-wide assessment is conducted to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies. […]

• No harm, potential for more than minimal, patternF684Apr 13, 2026

  Based on medical record review and staff interview it was determined that the facility staff failed to administer medications according to the physician orders. This was evident for 2 out 3 Resident (#16 and #7) reviewed during the complaint survey regarding medication administration.The findings include:Documentation is an integral part of medication administration. Documentation communicates the timing, dosing, and effect of any medications received by a patient. In the setting of skilled nursing care, residents are often prescribed multiple medications for significant medical conditions. They are also often more vulnerable to medication errors and more prone to changes in conditions that require review and adjustment of their medication regimen. […]

• No harm, potential for more than minimal, patternF804Apr 21, 2025

  Based on review of complaints, tray tickets, observation, and interview, it was determined the facility failed to serve residents food that was palatable and appealing and failed to follow the selections residents had chosen. This was evident for 13 (#10, #65, #63, #61, #68, #67, #66, #58, #70, #64, #62, #17, #71) of 73 residents reviewed during a complaint survey. The findings include: Review of complaints MD00202967, MD00206399, and MD00201718 alleged, inferior quality of food that was tasteless, cold, and often old. Badly cooked food without any nutrition or nourishment. Food was cooked raw with blood in it. I have been forced to order food regularly for my mother. […]

• No harm, potential for more than minimal, patternF761May 6, 2022

  Based on observations and interviews it was determined that the facility: 1) failed to ensure that medication carts were locked, code carts were locked, and medications were secure inside the medication cart. This was found to be evident for 3 out of 5 carts observed during the recertification survey and, 2) failed to ensure that medications were stored properly as evidenced by unopened insulin pens stored in medication carts. This was found to be evident for 2 out of 2 medication carts observed during medication storage observation. The findings include: 1) During a tour of the facility on 4/20/2022 the Surveyor observed an unlocked cart on the Light House unit unattended from12:06 PM- 12:12 PM located at the nurse's station, however no staff was around. […]