Autumn Lake Healthcare at Pikesville

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Aug 11, 2022

  Based on review of medical records and facility investigation documentation, interviews and observations it was determined the facility failed to have an effective system in place to prevent residents with cognitive impairment from leaving the facility without appropriate supervision. More specifically, the facility failed to: 1.) Provide adequate supervision to prevent a resident with known wandering and exit seeking behaviors from exiting the facility unsupervised on 5/10/21, 2.) Ensure all staff check the functionality of the wander guard bracelets for residents currently in the facility with a bracelet in place that have exit seeking behavior; 3.) have an elopement risk binder on all nursing units and educate all staff on the location and purpose of the elopement risk binder and 4.)… […]

• Actual harm, isolatedF600Aug 11, 2022

  Based on a facility-reported incident, closed clinical record review, staff interview, and reviews of the facility abuse policy, it was determined that facility staff failed to ensure a resident was free of staff abuse. This was evident for 2 (Resident #204, #412) out of 8 residents reviewed for abuse during an annual recertification survey. This deficient practice caused harm to Resident #204. The findings are: 1) A review of facility-reported incident MD 900 on 7/25/22 revealed that the facility reported an allegation of staff to resident abuse on 08/03/2020 in which the resident was observed with a bloody nose and a bleeding area to the resident's right lower leg stump. The facility also reported that the local police were notified and conducted an onsite investigation. […]

• No harm, potential for more than minimal, widespreadF570Aug 11, 2022

  Based on facility documentation review and interview, the facility staff failed to provide evidence the facility had purchased a surety bond to assure the security of all the residents' personal funds deposited with the facility. This was evident during the investigation of facility tasks during an annual survey. The findings include: On 8/9/22 at 11:45 AM, an inquiry was made with lobby receptionist (Staff #47) as to where the business office was located. It was revealed that the facility did not have a business office and she was responsible for passing out resident funds. Upon further questioning she indicated that she receives a weekly ledger listing the individual residents' current personal funds balances for the residents that have their personal funds managed by the facility. […]

• No harm, potential for more than minimal, widespreadF578Aug 11, 2022

  Based on clinical record review and staff interviews, it was determined that the facility failed to ensure the resident/responsible party was offered the opportunity to develop an advanced directive for 15 (#46, #76, #17, #87, #18, #28, #67, #1, #22, #49, #61, #95, #24, #75, #307) of 16 sampled residents for advanced directives. The findings include: An advance directive is a written statement of a person's wishes regarding medical treatment, often including a living will, made to ensure those wishes are carried out should the person be unable to communicate them to a doctor. […]

• No harm, potential for more than minimal, widespreadF584Aug 11, 2022

  Based on observation and interviews, it was determined that the facility failed to maintain a safe and clean environment as evidenced by 1) sagging ceiling tiles in resident rooms, 2) stained ceiling tiles, 3) walls in resident rooms that were in disrepair, 4) soiled linen and trash/debris on the floor and, 5) a rusted tube feeding pole. This was found to be evident throughout both floors of the facility. The findings include: 1) During the facility tours from 7/21/22 to 8/4/22, surveyors observed several resident rooms that had sagging ceiling tiles in their rooms. (Sagging ceiling tiles meant there was a space between the two attached tiles, and it looked like it was stuck down convexly.) -Room 110 above bed B: the second ceiling tiles from the wall had sagging ceiling tiles. […]