Autumn Lake Loch Raven: Wound Care Failures - MD
Resident 115 arrived at Autumn Lake Healthcare at Loch Raven on June 8, 2023, with a sacral pressure ulcer that required daily cleaning with saline solution and application of medihoney wound gel. The physician's order was clear: clean with normal saline, pat dry, apply medihoney on the sacral wound and cover with bordered foam, once daily.
Staff documented the wound during admission screening but failed to provide any treatment until June 10 — 48 hours later.
Four days after the delayed treatment began, the resident was hospitalized with lethargy. Hospital records show the resident had developed sepsis because the wounds were infected, according to a complaint that triggered the federal investigation.
The Director of Nursing told inspectors her expectation was that staff would remove the wound dressing during the admission assessment and immediately begin the physician-ordered treatment. She called waiting two days "unacceptable."
The resident had been bedridden at home before admission, developing the sacral ulcer that brought them to the facility. A wound specialist saw the resident on June 12 and recommended blood work and an X-ray of the sacral region to rule out infection. Those tests never happened — the resident was sent to the hospital that same day.
A second resident, number 113, experienced similar documentation failures that left gaps in basic pressure ulcer prevention care. The resident had physician orders for daily wound care and regular turning and repositioning to prevent additional sores.
Treatment records show staff failed to document wound care on June 10, 2024 and June 17, 2024. More concerning, positioning records revealed multiple days when staff failed to turn and reposition the resident as ordered.
The gaps were extensive. Staff failed to document turning and repositioning on June 4 night shift, June 8 day and night shifts, June 10 night shift, June 12 night shift, June 13 evening and night shifts, June 14 day shift, June 15 night shift, June 16 night shift, and June 17 day and evening shifts.
On two occasions — June 5 and June 15 — staff actually documented that the resident was not turned and repositioned at all.
The Director of Nursing acknowledged that nurses completing wound care are expected to document both the treatment provided and a description of the wound condition. She confirmed that whoever provides the wound care should record it in the treatment administration record.
When inspectors informed her of the missing documentation for Resident 113's wound care and positioning, she was made aware of the facility's failure to follow basic pressure ulcer prevention protocols.
Pressure ulcers develop when sustained pressure reduces blood flow to skin and underlying tissue. Bedridden residents require repositioning every two hours to prevent these painful wounds from forming or worsening. Once established, pressure ulcers can become infected and lead to life-threatening complications like sepsis.
The inspection, conducted in response to complaints about both residents, found that Autumn Lake Healthcare at Loch Raven failed to provide appropriate pressure ulcer care and prevent new ulcers from developing. Federal investigators determined the facility's failures resulted in minimal harm or potential for actual harm to residents.
Both cases revealed systemic problems with the facility's wound care protocols. For Resident 115, the failure was immediate — staff knew about the wound, had clear physician orders, but simply didn't follow them for two critical days when infection was taking hold.
For Resident 113, the failures were ongoing — staff either weren't providing required care or weren't documenting it, leaving no record of whether basic pressure ulcer prevention measures were being followed.
The inspection findings highlight how documentation failures can mask inadequate care, making it impossible to track whether vulnerable residents are receiving ordered treatments that could prevent serious complications.
Resident 115's case demonstrates the swift progression from delayed wound care to life-threatening infection. What began as a pressure ulcer requiring routine daily treatment escalated to sepsis requiring emergency hospitalization within days of the treatment delays.
The facility's own Director of Nursing acknowledged that immediate wound assessment and treatment upon admission is the standard of care, making the two-day delay particularly troubling for a resident already compromised by extended bed rest at home.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Autumn Lake Healthcare At Loch Raven from 2025-09-11 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
AUTUMN LAKE HEALTHCARE AT LOCH RAVEN in BALTIMORE, MD was cited for violations during a health inspection on September 11, 2025.
The physician's order was clear: clean with normal saline, pat dry, apply medihoney on the sacral wound and cover with bordered foam, once daily.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.