Autumn Lake Healthcare at Calvert Manor: Grievance Failures - MD
That is what federal inspectors found at Autumn Lake Healthcare at Calvert Manor during a complaint investigation completed in May 2026.
The family of Resident #12 had been raising concerns about Registered Nurse #23 for some time before filing a formal grievance on December 31, 2025. The grievance form, initiated by the facility that same day, resulted in a written resolution signed by Social Worker #22 and dated January 5, 2026. The corrective action was unambiguous: the nurse named in the complaint was aware he was not to treat the resident, per the daughter's request.
That was the agreement. What followed was something else entirely.
Inspectors pulled Resident #12's Medication Administration Record and Treatment Administration Record. RN #23 had documented medication administration and assessments of Resident #12 on January 9, January 19, February 8, February 12, April 23, and May 20, 2026. Staffing assignment sheets confirmed each date: the facility had placed RN #23 in direct charge of Resident #12's care on all six occasions, the first coming just four days after the grievance resolution was signed.
The resident's care plan contained no notation that RN #23 was prohibited from providing care. There was no written instruction in the medical record. Nothing in the documentation would have told a charge nurse reviewing assignments that this particular pairing was forbidden.
When inspectors raised their findings with the Director of Nursing and Social Worker #22 on the morning of May 22, both confirmed that the resolution meant what it said: RN #23 was not to care for Resident #12. Their explanation for how it failed was that they believed RN #23 had been verbally told. The Director of Nursing said she had been operating under the assumption, for nearly five months, that RN #23 had honored that instruction.
Nobody had checked.
A verbal conversation with one nurse, no entry in the care plan, no flag in the scheduling system. That was the entirety of the enforcement mechanism for a formal grievance resolution signed by a social worker and kept on file as an official facility document.
The family had complained to the facility multiple times about RN #23 before the December grievance made it formal. The inspection report does not describe what those earlier complaints concerned or what, if anything, the facility did in response to them before December 31. What the record shows is that when the family finally received a written commitment, the facility treated it as a matter already handled.
The gap between the grievance form and the care plan is where the failure lived. The grievance resolution existed in one filing system. The care plan, the document that actually governs how staff interact with a resident day to day, reflected none of it. Schedulers assigning RN #23 to Resident #12's hall had no way of knowing they were violating a months-old agreement, because no one had written it down where they would look.
Inspectors cited the deficiency as causing minimal harm or potential for actual harm, affecting few residents. One resident was reviewed for grievances. That resident was Resident #12.
The inspection report does not say what the family's original complaints about RN #23 involved, or how Resident #12 fared during the six shifts when the banned nurse provided care after the resolution took effect. It does not say whether the family knew, before inspectors arrived, that the agreement had not been honored. The family member who spoke with inspectors by phone on May 20 learned, at minimum, that the nurse had been assigned to their loved one that very morning, the same day the call took place.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Autumn Lake Healthcare At Calvert Manor from 2026-05-26 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: August 13, 2026 · Our methodology
AUTUMN LAKE HEALTHCARE AT CALVERT MANOR in RISING SUN, MD was cited for violations during a health inspection on May 26, 2026.
That is what federal inspectors found at Autumn Lake Healthcare at Calvert Manor during a complaint investigation completed in May 2026.
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.