Autumn Lake Healthcare At Ruxton
AUTUMN LAKE HEALTHCARE AT RUXTON in TOWSON, MD — inspection on February 25, 2026.
Found 6 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
through support of resident choice.
facility staff failed to ensure a resident received showers according to personal preference.
This was
findings include: During observation of Resident #104's wound dressing change on 2/20/26 at 2:50 PM the resident stated that he/she was supposed to get two showers twice a week in the evening but doesn't always get one.
Staff #15 who was doing the dressing change offered that the resident was supposed to get showers on the 3-11 shifts.
Resident said he/she wanted showers on the 7-3 shift and has told nursing staff that he/she wants showers on day shift because he/she wants the showers before wound dressings are changed not after.
The resident said even if the old dressing got wet it would have to come off anyway so getting wet would not matter.
The resident then stated that they did not get a shower on Tuesday, 2/17/26.This surveyor interviewed the Director of Nursing (DON) on 2/24/26 at 3:05 PM.
This surveyor explained the resident's concerns and preference for shower times.
The DON said she understood and would talk with the nurses on the unit to make necessary changes.A review of the facility's Documentation Survey Report on 2/24/26 revealed that the resident did not receive scheduled showers on 12/2/25, 12/5/25, 12/19/25, 12/22/25, 12/26/25, 12/30/25, 1/9/26, 1/13/26, 1/16/26, 1/20/26, 1/23/26, 1/27/26, 2/6/26, 2/13/26, 2/20/26.
The resident was marked as having received a shower on 2/17/26 but the resident denied receiving one.
The resident's sister was interviewed on 2/25/26 at 11:43 AM.
She was asked about the resident's showers.
She said that he/she has complained to the nursing staff about not getting showered and nursing staff tell him/her that he/she has to get showered at night even though he/she has told them he/she prefers to get showers during the day.
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
215077 02/25/2026
Autumn Lake Healthcare at Ruxton 7001 Charles Street Towson, MD 21204
Resident #180's resident representative, the Surveyor was informed that they filed grievances in
made aware of the progress of the facility's investigation or informed of the findings or resolutions to
conducted with the Director of Nursing (DON), the Surveyor was informed that if the resident or resident representative has a complaint/grievance, any staff member can receive the grievance and record specific information on the grievance form, they can assist the complainant to complete the form, or the complainant can fill the form out themselves.
The grievance form would then be sent to the Grievance Officer and distributed to the specific department manager to follow up with the complaint.
Once the department completes its investigation or determines a resolution, the form should be returned to NHA #1. NHA #1 is the Grievance Officer and oversees the grievance process.
The Surveyor requested NHA #1's date of hire.On 2/25/2026 at 2:27PM, an interview with Unit Manager #29 revealed that Resident #180's resident representative and UM #29 had numerous conversations regarding the care provided for the resident. UM #29 stated that any concerns the resident representative brought to their attention, were addressed with the resident representative as soon as possible. UM #29 does not recall receiving any complaint/grievance forms with concerns regarding Resident #180.On 2/25/2026 at 3:00PM, during an interview with the DON, the Surveyor confirmed that NHA #1 was hired on 2/24/2025.
The Surveyor expressed the concern that Resident #180's resident representative submitted Complaint/Grievance Forms on 1/17/2025, 2/3/2025, 2/4/2025, 2/9/2025, 2/10/2025, and 2/12/2025 and all forms were signed as completed by a Grievance Officer (unknown signature) and NHA #1 on 2/6/2025. 2/6/2025 was prior to NHA #1's hire and after grievances filed on 1/17/2025, 2/3/2025, and 2/4/2025.Further review of the Complaint/Grievance form, in the section, Facility Representative to complete the following, the facility failed to document who the concern was referred to, the date the form was received, and the date shared with the person filing the complaint/grievance.The Surveyor questioned the DON about the documentation on the Complaint/Grievance Forms and was unable to give an explanation.
The Surveyor also expressed the concerns that the facility failed to acknowledge receipt of the Complaint/Grievance Forms and inform Resident #180's resident representative of the findings and any resolutions to their concerns outlined on the forms. A review of the Resident and Family Grievances policy revealed that the Grievance Officer will issue a written decision on the grievance to the resident or resident representative and that documentation was not provided to the resident representative.
215077 02/25/2026
Autumn Lake Healthcare at Ruxton 7001 Charles Street Towson, MD 21204
Review of the MAR audit revealed the medication was not signed off as administered until 8:22 p.m.,
Oxybutynin Chloride Oral Tablet 5 mg and Midodrine HCl Oral Tablet 5 mg, scheduled for administration at 4:00 p.m.
Review of the MAR audit revealed both medications were not signed off as administered until 8:21 p.m., more than four hours after the scheduled time.
There was no documentation in the medical record to indicate the medications were held per physician order, refused by the resident, or delayed for a clinical reason.
There was no documentation of physician notification regarding the delayed administration.
During an interview with Staff #30 on 2/20/26 at 1:00 p.m., and during an interview with the Director of Nursing on 2/20/26 at 1:30 p.m., neither individual was able to provide a reason or documentation explaining why the medications were signed off as being administered late.
215077 02/25/2026
Autumn Lake Healthcare at Ruxton 7001 Charles Street Towson, MD 21204
This was evident for 1 (#104) out of 1 resident being reviewed for wound care.The findings
PM by a nurse (Staff #15).
While the nurse was changing the resident's dressing, Resident #104 stated that he/she asked for some pain medication at 2:30 PM but did not get any before wound care started.
Staff #15 interjected and said she was doing another resident's dressing change so she could not give him/her any pain medication before she started.
She asked the resident if they were in pain and the resident replied that they are in pain all of the time.
She said she would give him/her pain medication as soon as she finished.
The resident said that was acceptable.A review of Resident #104's clinical record on 2/24/26 revealed that the primary physician ordered on 2/4/26 Oxycodone 15 mg by mouth every 4 hours as needed for pain 5-10 on a 1-10 scale.
This surveyor interviewed the Director of Nursing (DON) on 2/24/26 at 3:05 PM.
The findings were explained to the DON.
She confirmed that the pain medication should have been administered prior to the would care.
She said she would get back to the survey team with any needed follow up.
215077 02/25/2026
Autumn Lake Healthcare at Ruxton 7001 Charles Street Towson, MD 21204
(#104) out 1 resident reviewed for pain medication.The findings are:A review of Resident #104's
mouth every 4 hours as needed for pain 5-10 on a 1-10 scale. A review of the Medication Administration Record revealed that: on 2/6/26 at 8:25 PM the resident's pain level was 4 but medication was administered, on 2/10/26 at 10:37 AM and 5:55 PM the resident's pain level was 4 but medication was administered, on 2/11/26 at 1:50 AM the resident's pain level was 4 but medication was administered, on 2/13/26 at 9:17 PM the resident's pain level was 4 but medication was administered, on 2/14/26 at 1:30 AM and 6:05 AM the resident's pain level was 4 but medication was administered, and on 2/15/26 at 4:33 PM and 8:55 PM the resident's pain level was 4 but medication was administered.Pain medication was administered when the pain level was 4, outside the parameters of the physicians order.
The Director of Nursing (DON) was interviewed on 2/24/26 at 3:05 PM.
She was informed of the findings and she agreed that the medication should not have been administered.
She said she would talk to the nurses involved.
215077 02/25/2026
Autumn Lake Healthcare at Ruxton 7001 Charles Street Towson, MD 21204
During a review of Resident #180's electronic medical record on 2/24/2026 at 8:15AM, the Surveyor discovered that [Dental Company] attempted to see the resident on 8/20/2024; however, the resident was not in the room or hallways; a dental exam was completed on 9/17/2024, with notation of (Nv prophy-next visit prophylaxis or routine cleaning); a dental hygiene encounter was attempted on 10/17/2024; however, the resident could not be seen due to isolation, and a dental exam was completed on 10/31/2025, with notation of (Nv prophy-next visit prophylaxis or routine cleaning).
Additional review failed to reveal documentation of a rescheduled dental hygiene encounter after the resident was unable to be seen on 10/17/2024's dental hygiene visit.
Further review of Resident #180's electronic medical record revealed a change in condition nursing note dated 10/25/2025 which stated tooth came out, left upper molar, the resident spit the tooth out while talking. No bleeding or pain noted.
The resident was ordered to be seen by dental services.
On 2/25/2026 at 11:30AM, an interview with the Director of Nursing (DON) revealed the facility does provide dental services to residents.
The DON stated that the [Dental Company] comes in monthly to see active residents.
The facility can refer residents for dental services as needed.
The Surveyor expressed the concern that Resident #180 was unable to be seen for a recommended dental hygiene appointment on 10/17/2024 and it was never rescheduled.
The last dental visit was documented, 10/31/2025, after the left upper molar tooth fell out on 10/25/2025 and the resident was ordered to be seen by dental services.