Autumn Lake Healthcare At Catonsville

Federal health inspectors cited AUTUMN LAKE HEALTHCARE AT CATONSVILLE in CATONSVILLE, MD for a deficiency under regulatory tag F-F0558 during a standard health inspection conducted on 2025-08-18.

Category: Resident Rights Deficiencies

The facility was found deficient in the following area: Reasonably accommodate the needs and preferences of each resident.

Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 23 deficiencies cited during this inspection of AUTUMN LAKE HEALTHCARE AT CATONSVILLE.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-22.

Federal health inspectors cited AUTUMN LAKE HEALTHCARE AT CATONSVILLE in CATONSVILLE, MD for a deficiency under regulatory tag F-F0559 during a standard health inspection conducted on 2025-08-18.

Category: Resident Rights Deficiencies

The facility was found deficient in the following area: Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 23 deficiencies cited during this inspection of AUTUMN LAKE HEALTHCARE AT CATONSVILLE.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-22.

Federal health inspectors cited AUTUMN LAKE HEALTHCARE AT CATONSVILLE in CATONSVILLE, MD for a deficiency under regulatory tag F-F0584 during a standard health inspection conducted on 2025-08-18.

Category: Resident Rights Deficiencies

The facility was found deficient in the following area: Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 23 deficiencies cited during this inspection of AUTUMN LAKE HEALTHCARE AT CATONSVILLE.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-22.

Federal health inspectors cited AUTUMN LAKE HEALTHCARE AT CATONSVILLE in CATONSVILLE, MD for a deficiency under regulatory tag F-F0604 during a standard health inspection conducted on 2025-08-18.

Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies

The facility was found deficient in the following area: Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 23 deficiencies cited during this inspection of AUTUMN LAKE HEALTHCARE AT CATONSVILLE.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-22.

During the interview Staff #26 stated Resident #135 had documented falls and that the no falls was an error and needed a modification to correct the error.On 8/12/25 at 1:53 PM, the surveyor conducted a follow-up phone interview with Staff #26.

During the interview Staff #26 confirmed that Resident #135 did not receive scheduled pain medications and the documentation was incorrect and was documented in error.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.

For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE

215097 08/18/2025

Autumn Lake Healthcare at Catonsville 16 Fusting Avenue Catonsville, MD 21228

Federal health inspectors cited AUTUMN LAKE HEALTHCARE AT CATONSVILLE in CATONSVILLE, MD for a deficiency under regulatory tag F-F0656 during a standard health inspection conducted on 2025-08-18.

Category: Resident Assessment and Care Planning Deficiencies

The facility was found deficient in the following area: Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 23 deficiencies cited during this inspection of AUTUMN LAKE HEALTHCARE AT CATONSVILLE.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-22.

Federal health inspectors cited AUTUMN LAKE HEALTHCARE AT CATONSVILLE in CATONSVILLE, MD for a deficiency under regulatory tag F-F0658 during a standard health inspection conducted on 2025-08-18.

Category: Resident Assessment and Care Planning Deficiencies

The facility was found deficient in the following area: Ensure services provided by the nursing facility meet professional standards of quality.

Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 23 deficiencies cited during this inspection of AUTUMN LAKE HEALTHCARE AT CATONSVILLE.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-22.

Federal health inspectors cited AUTUMN LAKE HEALTHCARE AT CATONSVILLE in CATONSVILLE, MD for a deficiency under regulatory tag F-F0677 during a standard health inspection conducted on 2025-08-18.

Category: Quality of Life and Care Deficiencies

The facility was found deficient in the following area: Provide care and assistance to perform activities of daily living for any resident who is unable.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 23 deficiencies cited during this inspection of AUTUMN LAKE HEALTHCARE AT CATONSVILLE.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-22.

During the interview the surveyor relayed the concern that if the skin condition/wound was not documented with characteristics and/or measurements weekly then how can the facility measure or know if the treatment is working or appropriate or if the wound is getting worse.

The RDON agreed that the wound documentation did not have documentation of a full assessment and would look to see if there was additional documentation.

The surveyor requested the facility's wound care policy Next the surveyor reviewed the policy titled, Documentation of Wound Treatments.

Guide line number 2 stated, the following elements are documented as part of a complete wound assessment: a, type of wound, b, stage of wound, c, measurement , and d, description of wound characteristics. At the time of exit no additional wound assessment was provided.

215097 08/18/2025

Autumn Lake Healthcare at Catonsville 16 Fusting Avenue Catonsville, MD 21228

Federal health inspectors cited AUTUMN LAKE HEALTHCARE AT CATONSVILLE in CATONSVILLE, MD for a deficiency under regulatory tag F-F0693 during a standard health inspection conducted on 2025-08-18.

Category: Quality of Life and Care Deficiencies

The facility was found deficient in the following area: Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 23 deficiencies cited during this inspection of AUTUMN LAKE HEALTHCARE AT CATONSVILLE.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-22.

During the interview the surveyor asked what the number referenced in Resident #135's pain monitoring documentation.

Specifically when it was documented that Resident #135 was confused and not able to communicate appropriately.

The RDON stated the PI was Pain Indicator and stated she would look to see if there was a pain code.

She further stated she would look to see Resident #135's pain evaluations to see how Resident #135's pain was assessed.

The surveyor reviewed the pain assessments with the RDON. On 9/29/23 Resident #135's pain evaluation documented yes to, appears different than usual behavior and indicated that Resident #135 had 10 out of the 13 behaviors listed as pain indicators.

The next question asked.

Can the resident indicate location and characteristic of pain? No was answered. On 10/2/23 a pain interview assessment was completed for Resident # 135. In the instructions it stated, complete pain assessment interview if the resident is able to communicate appropriately. If the resident is rarely or never understood, skip to section F.The assessment indicated the pain assessment interview should not be completed. On review of section F, titled, Indicator of pain or possible pain, the question is asked, should the staff assessment for pain be conducted? The answer was no and no additional assessment for pain was completed.

The surveyor reviewed the concern that Resident #135 was not appropriately assessed for pain on the pain assessment dated [DATE], when it was asked if the resident or staff interview should be completed and both questions were answered no.

Additionally, there was no basis provided for the daily pain assessments numbers that were documented on the MARs.

The surveyor asked for the pain policy.

Next the surveyor reviewed the policy titled, Pain Management. In the section, Pain Assessment #1 states, the facility will use a pain assessment tool, which is appropriate for the resident's cognitive status, to assist staff in consistent assessment of a resident's pain. In the monitoring section the policy states that facility staff will reassess resident's pain management at established intervals for effectiveness and or adverse consequences. On 8/12/25 at 2:18 PM, the surveyor reviewed the Controlled Drug Administration Records with the Assistant Director of Nursing (ADON) for Resident #135.

During the review it was noted that 6 doses of Morphine were taken.

The ADON confirmed that a pain assessment should have been completed every time the Morphine was given and a re-assessment should have been completed after to evaluate effectiveness. At the time of exit no additional pain assessments were provided to the surveyor.

Cross Reference F-F755

215097 08/18/2025

Autumn Lake Healthcare at Catonsville 16 Fusting Avenue Catonsville, MD 21228

Federal health inspectors cited AUTUMN LAKE HEALTHCARE AT CATONSVILLE in CATONSVILLE, MD for a deficiency under regulatory tag F-F0732 during a standard health inspection conducted on 2025-08-18.

Category: Nursing and Physician Services Deficiencies

The facility was found deficient in the following area: Post nurse staffing information every day.

Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 23 deficiencies cited during this inspection of AUTUMN LAKE HEALTHCARE AT CATONSVILLE.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-22.

and was not able to say if the provider was notified of the medications being held. On 8/14/25 at

recommended by a resident's specialist physician he would be responsible for coordinating

215097 08/18/2025

Autumn Lake Healthcare at Catonsville 16 Fusting Avenue Catonsville, MD 21228

Federal health inspectors cited AUTUMN LAKE HEALTHCARE AT CATONSVILLE in CATONSVILLE, MD for a deficiency under regulatory tag F-F0761 during a standard health inspection conducted on 2025-08-18.

Category: Pharmacy Service Deficiencies

The facility was found deficient in the following area: Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 23 deficiencies cited during this inspection of AUTUMN LAKE HEALTHCARE AT CATONSVILLE.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-22.

Federal health inspectors cited AUTUMN LAKE HEALTHCARE AT CATONSVILLE in CATONSVILLE, MD for a deficiency under regulatory tag F-F0812 during a standard health inspection conducted on 2025-08-18.

Category: Nutrition and Dietary Deficiencies

The facility was found deficient in the following area: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Scope/Severity Level F: widespread, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 23 deficiencies cited during this inspection of AUTUMN LAKE HEALTHCARE AT CATONSVILLE.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-22.

Federal health inspectors cited AUTUMN LAKE HEALTHCARE AT CATONSVILLE in CATONSVILLE, MD for a deficiency under regulatory tag F-F0814 during a standard health inspection conducted on 2025-08-18.

Category: Nutrition and Dietary Deficiencies

The facility was found deficient in the following area: Dispose of garbage and refuse properly.

Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 23 deficiencies cited during this inspection of AUTUMN LAKE HEALTHCARE AT CATONSVILLE.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-22.

observed Resident #20 documentation in Resident #6's paper medical record.

The documentation

the documents back in Resident #6 chart, RN #35 realized the documents belonged in Resident #20

On 8/13/25 at 9:29 AM, the surveyor reported to the Regional Director of Nursing Resident #20 medical documentation was in Resident #6 paper chart.

The Regional Director of Nursing verbalized the staff filed the documentation in the wrong chart.

215097 08/18/2025

Autumn Lake Healthcare at Catonsville 16 Fusting Avenue Catonsville, MD 21228

Federal health inspectors cited AUTUMN LAKE HEALTHCARE AT CATONSVILLE in CATONSVILLE, MD for a deficiency under regulatory tag F-F0880 during a standard health inspection conducted on 2025-08-18.

Category: Infection Control Deficiencies

The facility was found deficient in the following area: Provide and implement an infection prevention and control program.

Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 23 deficiencies cited during this inspection of AUTUMN LAKE HEALTHCARE AT CATONSVILLE.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-22.

Federal health inspectors cited AUTUMN LAKE HEALTHCARE AT CATONSVILLE in CATONSVILLE, MD for a deficiency under regulatory tag F-F0908 during a standard health inspection conducted on 2025-08-18.

Category: Environmental Deficiencies

The facility was found deficient in the following area: Keep all essential equipment working safely.

Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 23 deficiencies cited during this inspection of AUTUMN LAKE HEALTHCARE AT CATONSVILLE.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-22.

Federal health inspectors cited AUTUMN LAKE HEALTHCARE AT CATONSVILLE in CATONSVILLE, MD for a deficiency under regulatory tag F-F0919 during a standard health inspection conducted on 2025-08-18.

Category: Environmental Deficiencies

The facility was found deficient in the following area: Make sure that a working call system is available in each resident's bathroom and bathing area.

Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 23 deficiencies cited during this inspection of AUTUMN LAKE HEALTHCARE AT CATONSVILLE.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-22.

The surveyor noted that several recommendations were repeated throughout the treatment reports.

The pest management company wrote they observed voids (holes) in the kitchen on 2/24/25, 7/16/25 and 7/25/25. On 7/25/25 the comment stated, one of the voids in the kitchen still needs to be sealed. It also stated broken tiles were found that were holding dirty water in breakage under the floor.

The company also commented that this attracts roaches to the area.

Additionally the company recommended improving sanitation procedures.

This was recommended on 5/29/25, 7/16/25 and 7/24/25. On 7/24/25 the comments stated, poor sanitation throughout the kitchen and dish room area were observed.

Due to sanitation conditions, this can create and attract roaches; better cleaning procedures are needed for staff to follow. On 8/14/25 at 7 AM, two surveyors took a tour of the facility. In the first-floor ice room a void in the wall where a plumbing pipe was entering the room was stuffed with steel wool.

Additionally, what appeared to be a wet dirty towel was noted under the ice machine. On the back wall behind the machine there was debris, a few cup lids and a facemask on the floor. On 8/14/25 at 7:05 AM, the surveyors observed the kitchen.

Several cracked tiles were noted on the floor in the hallway just outside the chemical room. On 8/14/25 at 7:07 AM, the surveyors observed the area under the dishwasher. A lid to a pitcher, a bowel, a piece of wrapper and debris were noted. On further observation vermin droppings were noted.

Next the surveyor observed a French fry, wrappers and debris under the sink next to the drain. No French fries were being prepared during this observation On the back wall under the stainless steel preparation table, located next to the oven, there was noted vermin droppings.

The surveyor next observed the stainless steel preparation tables in the center of the kitchen.

Both tables had water accumulation under them.

The farther table had a piece of cut banana under it. No bananas were being prepped during the observations. On 8/14/25 at 7:14 AM, the surveyors observed the laundry area in the basement.

Multiple corners of the walls had rusted broken metal trim with what appeared to be holes in them.

Multiple sections of tile were broken. On 8/14/25 at 7:16 AM, the surveyors observed a bucket collecting drips from a leaking sink.

Tiles were broken under the sink. On 8/14/25 at 7:19 AM, the surveyors observed the clean laundry room. A chain of lint was noted alongside the side wall.

Behind a linen cart was a dried spill of brown substance, a bottle cap, a wrapper, and a shoe. On 8/14/25 at 7:23 AM, the surveyors observed the rehabilitation department.

Along the entrance wall vermin droppings were noted.

Further up the wall a pistachio nut was noted.

Debris, plastic cap and a ball were noted under the Air Condition (AC) unit. On 8/14/25 at 11:58 AM, the surveyor reviewed the observations and concerns that the facility had accumulated debris, vermin droppings in multiple areas throughout the facility with poor sanitation practices.

Cross Reference F-F925

215097 08/18/2025

Autumn Lake Healthcare at Catonsville 16 Fusting Avenue Catonsville, MD 21228

conference room.

The Licensed Nursing Home Administrator (LNHA) was notified at 12:00 PM;

Service Inspection Reports for the months of [DATE] and [DATE].

All State Pest Management was the contracted company that serviced the facility for pest control. On the [DATE] visit, the technician “inspected and treated all 4 nurses’ stations for occasional invaders; inspected and treated activity room for prior mice activity; deceased mouse was found under the refrigerator during the visit”. On the [DATE] service visit, the technician “inspected and treated all 4 nurses’ stations, kitchen area and dishwasher room, rehab gym and nourishment rooms for occasional invaders”. On the [DATE] service visit, the technician “inspected and treated kitchen area and dishwasher room, all 4 nurses’ stations, and rehab gym for occasional invaders; inspected and treated the country inn for prior mice activity; replenished RTUs (mouse bait stations) as needed”. On the [DATE] service visit, the technician “inspected and treated all 4 nurses’ stations and dining room for occasional invaders; inspected and treated the country inn office for prior mice activity”. On the [DATE] service visit, the technician “checked logbooks; mice activity reported in room [ROOM NUMBER]; inspected and treated kitchen area and dishwasher room, and all 4 nurses’ stations for occasional invaders; inspected and treated room [ROOM NUMBER] for mice activity”.

On [DATE] at 6:35 AM the survey team observed additional mouse droppings in the conference room behind boxes of copy paper.

The Licensed Nursing Home Administrator (LNHA) and the Regional Clinical Nurse were notified of the mouse droppings and acknowledged the surveyors.

In an interview with the Licensed Nursing Home Administrator (LNHA) at 7:10 AM on [DATE], the surveyor conveyed to the LNHA that there was a complaint submitted to the Office of Healthcare Quality (OHCQ) from a Resident’s family regarding a rodent in the facility.

Additionally, the surveyor conveyed that the All State Pest Management Service company found occasional invaders, mice, and evidence of mice activity during their weekly visits in various locations of the facility, including Resident rooms.

This concern with pests and rodents was indicated on the pest management service inspection reports that were reviewed by the surveyor from the company’s service visits on [DATE] through [DATE].

The LNHA acknowledged the surveyor’s concerns regarding pests and rodents in the facility.

At the time of the survey exit no additional information was provided by the facility related to maintaining an effective pest control program.