Autumn Lake Healthcare at Patuxent River: Care Plan Failures - MD
She was looking for transfer instructions. How to safely move a patient. She couldn't find them because they weren't there.
That gap, a missing entry in a care plan that should have told nurses and aides exactly how to move Resident 7 without causing harm, was the finding at the center of a complaint inspection completed October 17, 2025 at the Laurel facility.
Federal inspectors cited the home under F0656, which covers the requirement that facilities develop and keep current a comprehensive care plan for each resident. The deficiency was tagged at a level of minimal harm or potential for actual harm, affecting a small number of residents.
The nurse's confusion during the records review was not a one-person failure. Later that afternoon, at approximately 2:30 PM, inspectors sat down with the facility's Director of Nursing. The Director confirmed that nursing staff had not received any instructions about Resident 7's transfer status. Then the Director said what the missing care plan entry already made plain: the ADL care plan should have included a transfer status to guide staff in providing appropriate care and transfers.
Should have. Past tense. On the day inspectors were there, it still didn't.
At approximately 3:40 PM, the Administrator and the Director of Nursing were formally notified of the deficiency.
What the inspection report does not say is how long the transfer instructions had been missing, how many times staff moved Resident 7 without that guidance, or whether anyone was hurt. The record captures one afternoon: a nurse who didn't know, a Director of Nursing who confirmed the gap existed, and a care plan that was supposed to protect a resident and didn't.
Transfer is not a minor detail in a nursing home. Residents who need help moving, from bed to chair, from chair to toilet, from one position to another, depend on staff knowing exactly how to do it safely. The wrong technique, or no technique at all, can mean a fall, a fracture, or a pulled limb. A care plan entry specifying transfer status is how that knowledge travels from a physician's assessment to the hands of a nursing assistant working a night shift who may have never met the resident before.
At Autumn Lake Healthcare at Patuxent River, that chain broke somewhere. The nurse reviewing the chart during the inspection didn't know where to look. The Director of Nursing acknowledged staff had never been told. Neither of those people invented the failure on the spot. The gap was in the system before inspectors walked through the door.
The facility is located at 14200 Laurel Park Drive in Laurel, and is identified in federal records under provider number 215141. The inspection was conducted as a complaint survey, meaning someone had raised a concern before inspectors arrived.
The care plan for Resident 7's activities of daily living was there. The eating task was there. The transfer status was not.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Autumn Lake Healthcare At Patuxent River from 2025-10-17 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 8, 2026 · Our methodology
AUTUMN LAKE HEALTHCARE AT PATUXENT RIVER in LAUREL, MD was cited for violations during a health inspection on October 17, 2025.
She was looking for transfer instructions.
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.