Autumn Lake Healthcare At Baltimore Washington
AUTUMN LAKE HEALTHCARE AT BALTIMORE WASHINGTON in GLEN BURNIE, MD — inspection on October 30, 2025.
Found 1 citation. 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
Based on record reviews and interviews it was determined that the facility staff failed to ensure maintenance care was provided to a resident's tube feeding device.
This was evident for 1 (#8) of 1 resident reviewed for tube feedings.
The findings include:Percutaneous Endoscopic Gastrostomy (PEG) tube is a thin, flexible tube inserted into the stomach through a small incision in the abdominal wall. It provides a way to deliver nutrition and medications directly into the stomach when a person cannot eat or drink orally.During a review of complaint # 2599868 on 10/27/25 at 7:52 AM it was reported that flushes were not being completed daily on the PEG tube for Resident #8.During a review of medical records on 10/27/25 at 12:14 PM it was discovered that the Resident #8 had a PEG Tube placed on 7/25/25 and was in place upon his/her admission to the facility on 8/12/25.
During additional review of the orders for Resident #8 It was revealed that there were no orders placed for monitoring or flushing the PEG tube upon admission to the facility.
There were orders added for the PEG tube on 8/19/25 which stated to Flush with 5 - 10 milliliters Twice a day, an order to inspect surrounding skin of stoma/nares for redness/tenderness, swelling, irritation, purulent drainage, or signs of infection and an additional order to Complete tube site care and change syringe daily.
There was no documentation of the tube being flushed or monitored prior to the orders being added to the Medication Administration Record.
During an interview with Unit Manager #14 on 10/28/25 at 9:25 AM she reported she would expect orders for PEG tube care to be placed upon admission that would include monitoring the PEG site for infection and providing water flushes.
She reported Resident #8 was able to eat and drink by mouth and the PEG tube was not being used.
She confirmed water flushes would still be expected to be completed in residents that are not currently receiving tube feeding.
She reported she would have expected Resident #8 to have received the water flushes sooner than was ordered.During an interview with the Director of Nursing (DON) on 10/28/25 at 11:46 AM she reported she would expect Resident #8 to have had orders for flushing upon his/her admission because there's an order set that could be entered by the nursing staff.
The order set would have included monitoring the site of placement and providing maintenance flushing to the PEG tube.
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.
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