Autumn Lake Healthcare At Riverview
AUTUMN LAKE HEALTHCARE AT RIVERVIEW in ESSEX, MD — inspection on April 30, 2026.
Found 5 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Review of a 4/3/26 nurse practitioner initial evaluation note documented, pain and opioid management, patient is at high risk for poor function improvement in therapy without adequate pain management.
The pain medication that was prescribed from the hospital and was to be continued on at the facility included Hydromorphone 6 mg (opioid) every 4 hours when needed (prn), Hydromorphone 4 mg every 4 hours prn, Tylenol 1 gram every 6 hours prn, Lidocaine cream to the back every 6 hours prn, Methocarbamol (muscle relaxant) 500 mg. every 6 hours prn, Celebrex 100 mg. twice per day, and Gabapentin 300 mg. three times a day.
Review of a physician's note dated 4/8/26 at 12:42 PM documented, the patient reportedly had opioid overdose earlier this morning around a.m. and responded well to Narcan administration by nursing.
Chronic pain, opioid overdose s/p Narcan.
Further review of Resident #11's medical record failed to produce documentation that Resident #11's representative was notified of the incident. On 4/27/26 at 10:46 AM Licensed Practical Nurse (LPN) #4 (agency nurse) was interviewed and stated that Resident #11 was out of it and not responding when LPN #4 was doing rounds, so LPN #4 went to see if there was an order for Narcan. LPN #4 found the order and administered the Narcan and Resident #11 responded. On 4/27/26 at 10:55 AM an interview was conducted with the Director of Nursing (DON).
The DON stated she would have expected the responsible party to be notified. On 4/27/26 at 1:09 PM LPN #19 was interviewed and stated the nurse administered the Narcan as the resident looked like the he/she was having an overdose.
The physician saw the resident afterwards. LPN #19 stated, I don't think anyone was notified, but should have been.
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
215203 04/30/2026
Autumn Lake Healthcare at Riverview 1 Eastern Boulevard Essex, MD 21221
Review of Resident #10's February 2026 Medication Administration Record (MAR) failed to produce documentation that Resident #10 received pain medication daily.On 4/30/26 at 12:45 PM LPN) #17 stated that she coded that way because Resident #10 received Aspirin 81 mg. every day as a prophylactic.
The Aspirin should not have been coded as pain medication as that was not the intent for the medication.On 4/30/26 at 2:00 PM the Nursing Home Administrator and the Director of Nursing were informed of the MDS coding concerns.
215203 04/30/2026
Autumn Lake Healthcare at Riverview 1 Eastern Boulevard Essex, MD 21221
Review of a physician's note dated 4/8/26 at 12:42 PM documented, the patient reportedly had opioid overdose earlier this morning around a.m. and responded well to Narcan administration by nursing.
Chronic pain, opioid overdose s/p Narcan.
Further review of Resident #11's medical record failed to produce a nursing assessment of the resident.
There was no nursing documentation of what the resident's condition was and what the vital signs were at the time.
There was no documentation that the Narcan was administered and what the resident's response was after the Narcan was administered.
On 4/27/26 at 10:46 AM Licensed Practical Nurse (LPN) #4 (agency nurse) was interviewed and stated that Resident #11 was out of it and not responding when LPN #4 was doing rounds. LPN #4 stated that she knew Resident #11 was on little pills real heavy and the roommate told me that [he/she] was acting crazy the previous night and couldn't get any rest.
The vitals were fine, so I went to see if there was an order for Narcan. LPN #4 found the order and administered the Narcan and Resident #11 responded and was his/her normal self. LPN #4 stated they monitored the resident and they knew the doctor was on the way and when the doctor got there all of the pain meds were discontinued and he/she just had 2 pain meds.
LPN #4 was asked by the surveyor if she did a change in condition after the Narcan was administered. LPN #4 stated, I don't know if a change a condition, what the P and P (policy and procedure) is because this is the first time I had to give the Narcan. I don't know since the order was there. I didn't document it.
On 4/27/26 at 10:55 AM an interview was conducted with the Director of Nursing (DON).
The DON stated she would have expected to see a change in condition in the resident's medical record along with an assessment and vital signs.
On 4/27/26 at 1:09 PM LPN #19 was interviewed and stated she was the unit manager. LPN #19 stated the nurse administered the Narcan as the resident looked like the he/she was having an overdose.
The physician saw the resident afterwards. LPN #19 stated, The nurse should have done an assessment and taken vital signs of the resident.
215203 04/30/2026
Autumn Lake Healthcare at Riverview 1 Eastern Boulevard Essex, MD 21221
Observation was made of disinfectant wipes sitting on a wire shelf.
The wording on the containers stated, store in original container in areas inaccessible to children.
The back of the contained stated, do not use as a diaper wipe or for personal cleansing.
This is not a baby wipe.At the time of the observation Geriatric Nursing Assistant (GNA) #18 was in the dining room with the residents while they were waiting for breakfast.
The unit manager, Licensed Practical Nurse (LPN) #13 was with the surveyor during the observation.
The surveyor expressed concern about the wipes in a public area where residents with cognitive impairment were located. LPN #13 immediately removed the wipes from the dining room.
LPN #13 came back to the room and stated she had never seen any residents use the wipes or attempt to use the wipes. LPN #13 stated that staff use the wipes to wipe down the tables before and after meals.On 4/30/26 at 8:15 AM an interview was conducted with GNA #18 who stated that she was always in the dining room when the residents are in the dining room and that the residents are never left alone. GNA #18 was asked if the doors to the dining room were always kept open during the day and she stated they were. GNA #18 also stated she never saw a resident use a wipe.On 4/30/26 at 8:21 AM an interview was conducted with the Infection Control Nurse (ICP) #10.
She stated she was not aware that the disinfectant wipes were a concern in the dining room because no residents had ever gone near them. ICP #10 stated, they are for staff use to wipe down the tables.On 4/30/26 at 9:45 AM an interview was conducted with the Nursing Home Administrator (NHA) and the Director of Nursing (DON).
They stated that they were never made aware of the concern with the wipes.
The DON stated that she understood the concern.
215203 04/30/2026
Autumn Lake Healthcare at Riverview 1 Eastern Boulevard Essex, MD 21221
Review of both records revealed that Resident #11's April 2026 MAR was blank on the following days when the Hydromorphone was signed out by a licensed nurse on the Controlled Drug Administration Record for Resident #11. On 4/9/26 not signed off on MAR but on narcotic sheet the medication was signed out as given at 8:00 AM, 1:00 PM, 5:00 PM, and 10:00 PMOn 4/10/26 not signed off on MAR but on narcotic sheet the medication was signed out as given at 8:00 AM and 1:30 PM.On 4/11/26 not signed off on MAR but on narcotic sheet the medication was signed out as given at 11:37 PM.On 4/12/26 not signed off on MAR but on narcotic sheet the medication was signed out as given at 8:00 PM.On 4/13/26 not signed off on MAR but on narcotic sheet it was signed out as given at 6:30 PM.On 4/15/26 not signed off on MAR but on narcotic sheet it was signed out as given at 12:00 AM.On 4/27/26 at 10:46 AM an interview was conducted with Licensed Practical Nurse #4 who stated, I sign out on the narcotic sheet, but I do not document it on the MAR.On 4/27/26 at 10:55 AM the Director of Nursing (DON) was interviewed and stated, I am aware the nurses are signing off on the Narcotic sheet but not the MAR and I am going to have to educate them that they have to sign off on the MAR that the medication was administered.On 4/27/26 at 1:09 PM LPN #19, the unit manager stated, I am not aware that the nurses were not signing off on the MAR when they are also signing off on the narcotic sheet.
They need to document on the MAR and the narcotic sheet.On 4/30/26 at 9:45 AM an interview was conducted with the Nursing Home Administrator (NHA) and the DON.
They stated that they were not aware of the concern until the surveyor pointed it out and that they both agreed with the findings.
Frequently Asked Questions
More Reports
Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.