Deficiencies (last 3 years)
Deficiencies (over 3 years)
23.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
85% worse than Maryland average
Maryland average: 12.8 deficiencies/yearDeficiencies per year
24
18
12
6
0
Inspection Report
Routine
Deficiencies: 7
Aug 18, 2025
Visit Reason
The inspection was conducted as a routine survey to assess compliance with healthcare regulations and standards at Autumn Lake Healthcare at Catonsville.
Findings
The facility was found deficient in multiple areas including accurate resident assessments, wound documentation, pain management, medication administration, medical record maintenance, sanitation, and pest control. Several residents' records showed inaccurate or incomplete documentation, and the facility had ongoing issues with vermin and sanitation in multiple areas.
Complaint Details
Complaint #292313 involved a report that facility staff left a mouse on a trap in Resident #143's room for 10 hours before removal. The complaint was substantiated by observations of mouse droppings and pest activity documented by the pest management company and surveyors.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 7
Deficiencies (7)
| Description | Severity |
|---|---|
| Failure to accurately document a discharge Minimum Data Set (MDS) assessment for Resident #135. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to adequately document wounds and responses to treatment of skin conditions for Resident #138. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to utilize an appropriate pain assessment based on a Resident's cognitive status for Resident #135. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide pharmaceutical services to meet the needs of residents, including medication administration documentation errors for Residents #135 and #137. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to maintain medical records in accordance with accepted professional standards and filing documents in the correct resident's medical record. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to keep a sanitary environment with vermin droppings and debris in multiple facility areas including kitchen, laundry, and rehabilitation rooms. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to maintain an effective pest control program despite repeated recommendations and documented pest activity. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed: 60
Residents reviewed for wounds: 2
Residents reviewed for pain: 4
Residents reviewed for medication regimen: 7
Doses of Morphine taken: 6
Doses of Lorazepam taken: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff #26 | MDS Coordinator | Interviewed regarding Resident #135's MDS assessment and pain medication documentation |
| Regional Director of Nursing | RDON | Interviewed regarding wound documentation, pain management, medication administration, and pest control |
| Assistant Director of Nursing | ADON | Interviewed regarding medication administration and pain assessment for Resident #135 |
| Physician #27 | Physician | Interviewed regarding expectations for medication notification and coordination |
| Director of Nursing | DON | Interviewed regarding oxygen documentation for Resident #132 and hospice documentation for Resident #135 |
| Registered Nurse #35 | RN | Noted misfiling of Resident #20 documentation in Resident #6's chart |
| Licensed Nursing Home Administrator | LNHA | Interviewed regarding pest control program and complaint about rodent in facility |
Inspection Report
Annual Inspection
Deficiencies: 19
Aug 7, 2025
Visit Reason
The inspection was a recertification annual survey to assess compliance with regulatory requirements for Autumn Lake Healthcare at Catonsville.
Findings
The survey identified multiple deficiencies including failure to provide dignified care, inadequate call bell availability, failure to accommodate married residents wishing to share a room, poor environmental cleanliness, improper use of physical restraints, incomplete care plan implementation, medication administration errors, unmet ADL needs, improper feeding tube care, incomplete nurse staffing information, medication storage and labeling issues, improper garbage disposal, inadequate infection control, unsafe equipment, malfunctioning call systems, unsanitary conditions, and ineffective pest control.
Complaint Details
Complaint #292313 involved a report that facility staff left a mouse on a trap in Resident #143's room for 10 hours before removal. Pest control records showed ongoing mice activity and ineffective pest control measures.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 19
Deficiencies (19)
| Description | Severity |
|---|---|
| Facility staff failed to provide dignified existence to residents by storing clothing in garbage bags, shoes and bed pan in wheelchairs, and failing to repair furniture. | Level of Harm - Minimal harm or potential for actual harm |
| Facility staff failed to ensure residents on Unit C had call bells to notify staff of their needs. | Level of Harm - Minimal harm or potential for actual harm |
| Facility staff failed to accommodate a married couple residing separately who wished to share a room. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to provide clean and sanitary carpets and maintain a clean and comfortable homelike environment. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to provide documentation for use of physical restraint related to bed placement against wall. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to implement comprehensive person-centered care plans including timely toileting and oxygen supply needs. | Level of Harm - Minimal harm or potential for actual harm |
| Facility staff failed to practice according to professional nursing standards including medication preparation, administration, and documentation errors. | Level of Harm - Minimal harm or potential for actual harm |
| Facility staff failed to consistently provide ADL care to a dependent resident including incontinence care. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to ensure tube feeding bags were properly labeled and securely closed to prevent contamination. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to update nurse staffing boards timely and include all required components on posted nurse staffing information sheets. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to properly store and label medications and biologics, including multi-dose medications and wasted pills, and failed to secure medication cart. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to maintain proper food labeling, dating, and expiration practices and improperly thawed raw meat in sanitizing sinks. | Level of Harm - Minimal harm or potential for actual harm |
| Facility staff failed to dispose of garbage and refuse properly as evidenced by waste bags, COVID-19 test kits, and debris around dumpster. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to safeguard resident-identifiable information and maintain medical records in accordance with professional standards, including misfiled documents and incomplete documentation. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to provide alcohol-based sanitizer and cold running water for hand hygiene and maintain infection control precautions with residents' urinal use. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to maintain equipment in safe operating condition including exposed wires, non-functioning lights, and bed alarms. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to ensure working call system was available in residents' bathrooms and bathing areas, including accessible call bells and operable call bell lights. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to keep nursing home areas safe, clean, and comfortable, with vermin droppings, debris, broken tiles, rust, and poor sanitation in multiple areas including kitchen, laundry, and rehab. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to maintain an effective pest control program as evidenced by recurrent pest management recommendations and observed vermin droppings. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 7
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 4
Residents affected: 2
Residents affected: 3
Residents affected: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| GNA #36 | Geriatric Nursing Assistant | Confirmed clothing stored in garbage bags and discussed call bell procedures |
| GNA #30 | Geriatric Nursing Assistant | Described call bell checks on Unit C |
| GNA #31 | Geriatric Nursing Assistant | Described call bell checks on Unit C |
| Social Services Director #1 | Social Services Director | Interviewed about married residents' room sharing |
| Administrator | Interviewed about multiple deficiencies including clothing storage, married residents, call bell system, and pest control | |
| RN #28 | Registered Nurse | Confirmed Resident #4 did not have call bell |
| Staff #8 | Geriatric Nursing Assistant | Interviewed about Resident #39 bed placement and fall mat |
| Staff #10 | Licensed Practical Nurse | Interviewed about Resident #39 bed placement and fall mat |
| Regional Director of Nursing | Regional Director of Nursing | Interviewed about medication administration errors and bed placement |
| Staff #9 | Nurse | Noted Resident #59 anxiety and care issues |
| Unit Manager Staff #15 | Unit Manager | Assessed Resident #59 care issues and identified staff non-compliance |
| LPN #33 | Licensed Practical Nurse | Observed medication preparation errors and failed to provide incontinence care |
| Staff #21 | Geriatric Nursing Assistant | Identified as night shift staff not assisting Resident #59 |
| Staff #25 | Interviewed about missing call bell system in rehab bathroom | |
| Maintenance Director #14 | Maintenance Director | Interviewed about dumpster maintenance and facility maintenance concerns |
| RN #3 | Registered Nurse | Observed leaving medication cart unlocked |
| LPN #8 | Licensed Practical Nurse | Informed about undated medications |
| LPN #9 | Licensed Practical Nurse | Informed about loose pills in medication cart |
| RN #35 | Registered Nurse | Filed documents in wrong resident chart |
| GNA #11 | Geriatric Nursing Assistant | Responded to call bell activation for Resident #52 |
| LPN Supervisor #29 | Licensed Practical Nurse Supervisor | Explained why staffing boards were not updated |
| Director of Nursing | Director of Nursing | Interviewed about multiple deficiencies including infection control, medication administration, and call bell system |
Inspection Report
Annual Inspection
Deficiencies: 3
Mar 24, 2023
Visit Reason
The inspection was conducted as part of the annual survey to review compliance with discharge documentation, discharge planning, and pressure ulcer care.
Findings
The facility failed to document resident discharge adequately, delayed providing family-requested legal documentation affecting discharge planning, and failed to monitor and document treatments for pressure ulcers, resulting in minimal harm or potential for harm to a few residents.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure discharge/transfer documentation including resident's status and discharge instructions for Resident #171. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to implement effective discharge planning by delaying family-requested legal documentation, affecting Resident #376's discharge. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to monitor and document treatments and services to promote healing of pressure ulcers for Resident #372. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for discharge: 3
Residents reviewed for discharge during complaint survey: 4
Residents reviewed for pressure ulcers: 4
Pressure ulcer size: 4
Pressure ulcer size: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Collaborated with surveyor on discharge documentation for Resident #171 and discussed delayed discharge planning and wound care |
Inspection Report
Annual Inspection
Deficiencies: 18
Mar 24, 2023
Visit Reason
The inspection was conducted as part of the annual survey and complaint investigations to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found to have multiple deficiencies including failure to treat residents with dignity, failure to involve residents in care planning, inadequate maintenance and housekeeping, incomplete investigations of abuse allegations, failure to notify residents of bed hold policies, inaccurate assessments and care plans, inadequate assistance with activities of daily living, medication errors, improper medication storage, failure to maintain accurate medical records, inadequate food service, and unsafe environmental conditions.
Complaint Details
The complaint investigations revealed failures in abuse investigations, wound care, blood sugar monitoring, medication administration, and resident rights including care planning and notification of bed hold policies.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 17
Deficiencies (18)
| Description | Severity |
|---|---|
| Failure to treat residents in a dignified manner including leaving a urinal with urine on bedside table and standing over a resident while feeding. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to allow resident to participate in the development and implementation of his or her person-centered plan of care. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide notice of rights and services to a resident upon admission. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to maintain a safe, clean, comfortable, and homelike environment including housekeeping and maintenance deficiencies throughout the facility. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to thoroughly investigate allegations of abuse, neglect, misappropriation of resident property, and injuries of unknown source. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to notify resident or representative in writing of bed hold policy upon transfer to acute care. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to conduct accurate Minimum Data Set (MDS) assessments including omission of vision problems. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide residents with a copy of their baseline care plan and admission medications. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to develop comprehensive, resident-centered care plans with measurable goals and timely interdisciplinary team involvement. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide care and assistance for activities of daily living including grooming and personal hygiene. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide appropriate treatment and care according to orders including medication administration errors, wound care, blood sugar monitoring, incontinent care, and specialist appointments. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to maintain accurate account of controlled substances with discrepancies in narcotic counts and incomplete documentation. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to properly label and store medications, COVID test supplies, and resident care equipment in medication rooms and carts. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure documented new psychotic diagnosis before medication initiation. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to accurately document behavior monitoring, interventions, and effectiveness in medical records. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to develop and implement policies and procedures for influenza and pneumococcal vaccinations including documentation of consents. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide at least one adequate resident dining room with sufficient space, lighting, and furniture. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure that nursing home area is safe, easy to use, clean and comfortable including maintenance of ventilation ducts. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Medication error rate: 7.69
Resident beds in A, C, D wings: 100
Medication cart narcotic discrepancies: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff #3 | Unit Manager | Named in findings related to feeding residents and care plan meetings |
| Staff #6 | Social Services Director | Named in findings related to care plan meetings and grievance documentation |
| Staff #15 | Unit Manager | Named in findings related to resident care, medication administration, and wound care |
| Staff #11 | Registered Nurse | Named in medication storage and administration findings |
| Staff #22 | Nurse | Named in medication administration observation with errors |
| Staff #25 | Physician Assistant | Named in findings related to psychiatric diagnosis documentation |
| Staff #24 | Physician (Medical Director) | Named in findings related to psychiatric diagnosis documentation |
| Staff #41 | Regional Nurse | Named in wound care findings |
| Staff #19 | Wound Nurse | Named in wound care findings |
| Staff #20 | Social Worker | Named in care plan meeting and documentation findings |
| Staff #30 | Staff Scheduler | Named in staffing posting findings |
| Staff #5 | Food Service Manager | Named in food service and kitchen condition findings |
Inspection Report
Annual Inspection
Census: 49
Capacity: 136
Deficiencies: 24
Dec 21, 2018
Visit Reason
The inspection was conducted as part of the facility's annual recertification survey and included observations, interviews, and record reviews to assess compliance with regulatory requirements.
Findings
The survey identified multiple deficiencies including failure to treat residents with dignity and respect, inadequate assistance with dining positioning, unsanitary and poorly maintained environment, failure to conduct background checks, untimely reporting of abuse, incomplete discharge documentation, inaccurate resident assessments, incomplete and inaccurate care plans, failure to provide proper grooming and hygiene, inadequate range of motion care, unsafe environment for fall risk residents, improper medication management, food service deficiencies, infection control lapses, and inadequate quality assurance program.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 23
Level of Harm - Potential for minimal harm: 1
Deficiencies (24)
| Description | Severity |
|---|---|
| Facility staff failed to treat residents with dignity and respect, evidenced by a Geriatric Nursing Assistant standing while feeding residents and verbally mistreating residents. | Level of Harm - Minimal harm or potential for actual harm |
| Facility staff failed to accommodate residents' individual dining needs by not providing assistance with positioning for dining. | Level of Harm - Minimal harm or potential for actual harm |
| Facility staff failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior environment. | Level of Harm - Minimal harm or potential for actual harm |
| Facility staff failed to put a system in place to ensure background screens were conducted prior to hiring staff to prevent abuse, neglect, exploitation, and misappropriation. | Level of Harm - Potential for minimal harm |
| Facility failed to timely report an allegation of abuse to the State Agency. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to document a resident's discharge in the medical record. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to orient, prepare and document a resident's preparation for hospital transfer. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to ensure accurate Minimum Data Set (MDS) assessments and coding for multiple residents. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to provide resident and representative with a summary of baseline care plan including medications and dietary instructions within 48 hours of admission. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to develop and implement comprehensive, accurate resident-centered care plans with measurable goals and timely revisions. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to honor residents' preferences, choices, values and beliefs by failing to ensure proper positioning of a dependent resident for dining. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to provide care and assistance to maintain good grooming and personal hygiene for a dependent resident. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to provide appropriate care for residents with limited range of motion and contractures to prevent further decline. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to ensure resident environment was free from accident hazards by leaving a fall risk resident's bed in a high position and not assisting with proper positioning for meals. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to provide appropriate care for a resident with a Foley catheter including lack of physician order, care plan, and documented care. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to provide safe, appropriate pain management including lack of complete pain assessments and failure to implement pain care plan. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to conduct yearly performance reviews for Geriatric Nursing Assistants as required. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to properly label and store drugs and biologicals, including storing medicated creams and lotions in resident's room without proper orders or plans of care. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to ensure meals and snacks were served with no more than 14 hours between dinner and breakfast, and failed to provide substantial evening snacks. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to procure food from approved sources, maintain sanitary food service equipment, ensure dietary staff compliance with hair/beard restraints, distribute and store food under sanitary conditions, and monitor dishwasher and freezer temperatures. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to safeguard resident-identifiable information and maintain accurate medical records, including inaccurate documentation of tobacco use and elopement assessment. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to implement and maintain an infection prevention and control program including ensuring sanitary resident equipment, timely replacement of care equipment, monitoring laundry chemical use, and screening newly hired staff for communicable diseases. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to keep essential equipment, specifically the kitchen walk-in freezer, in safe operating condition. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to have an effective quality assessment and assurance program by failing to implement corrective plans of action for deficiencies identified during the prior annual survey. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed: 49
Total bed capacity: 136
Fall risk assessment score: 9
Missed medication doses: 10
Potable water gallons on hand: 120
Potable water gallons required: 408
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff #18 | Named in findings related to dining positioning and fall risk resident care | |
| Staff #6 | Director of Nursing | Acknowledged findings related to dignity, abuse reporting, and quality assurance |
| Staff #9 | Environmental Services Manager | Interviewed regarding environmental and laundry issues |
| Staff #10 | Food Service Director | Interviewed regarding kitchen and dietary deficiencies |
| Staff #26 | Interviewed regarding contractures and range of motion care | |
| Staff #3 | Confirmed missed medication doses for Resident #42 | |
| Staff #17 | Unit Manager | Interviewed regarding wound care documentation |
| Staff #22 | Interviewed regarding Foley catheter care | |
| Staff #24 | Interviewed regarding bathroom sanitation | |
| Staff #25 | Notified about resident positioning for dining | |
| Staff #31 | Nurse Practitioner | Documented inaccurate tobacco use in medical record |
| Staff #32 | Physician | Documented inaccurate tobacco use in medical record |
| Staff #33 | Attending Physician | Documented inaccurate tobacco use in medical record |
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