Autumn Lake Healthcare At Baltimore Washington
Inspection Findings
F-Tag F0693
F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
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.
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.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
Facility ID:
If continuation sheet
Event ID:
AUTUMN LAKE HEALTHCARE AT BALTIMORE WASHINGTON in GLEN BURNIE, MD inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in GLEN BURNIE, MD, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from AUTUMN LAKE HEALTHCARE AT BALTIMORE WASHINGTON or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.