Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Advanced Rehab At Autumn Lake Healthcare during CMS and state inspections, most recent first.
The facility did not ensure that comprehensive care plans addressed residents' medical needs, including oxygen therapy and psychiatric medication, nor did it update care plans following significant changes such as hospice admission. Additionally, required quarterly care plan meetings were not conducted for a resident with ongoing sensory concerns, and documentation of these meetings was not available.
Surveyors found that the facility did not consistently ensure narcotic record books were signed by both incoming and outgoing nurses, failed to maintain drug records that accounted for all controlled drugs, and did not administer medications according to physician-ordered parameters. This included cases where a resident's controlled substance was removed from supply without corresponding documentation of administration, and instances where residents received pain and blood pressure medications outside of prescribed parameters, with required non-pharmacological interventions not documented.
The facility failed to conduct thorough investigations and maintain documentation for abuse allegations involving four residents. Investigations lacked interviews, signed statements, and complete reports. The DON and Administrator acknowledged these deficiencies, which were discussed at the exit conference.
The facility failed to follow professional nursing standards in medication administration, resulting in delayed medication for several residents. A resident reported not receiving PRN oxycodone on time, and audits confirmed multiple medications were administered hours late. Further reviews showed a pattern of late documentation and administration for other residents, indicating systemic issues.
The facility failed to report alleged abuse within the required 2-hour timeframe. An incident involving alleged abuse was reported late to the state agency, and a resident's report of verbal abuse by an RN was not immediately reported to the state office or law enforcement. The facility's policy requires immediate reporting of such allegations.
The facility failed to develop and implement comprehensive care plans for two residents. One resident with Type 1 Diabetes Mellitus did not have a diabetes care plan, despite receiving insulin. Another resident with respiratory issues was not included in a care plan meeting and lacked a respiratory care plan, contrary to the facility's Oxygen Administration policy.
The facility failed to follow physician orders for three residents, resulting in deficiencies in care. A resident with lymphedema was not provided with prescribed ACE wraps, another resident received incorrect dosages of pain medication, and a third resident was given an incorrect oxygen flow rate. These issues were due to confusion over orders, lack of EHR access, and lapses in monitoring.
The facility failed to document whether a resident showed signs of abuse following an allegation and did not verify monthly pharmacy reviews for two residents. The medical record for a resident lacked evidence of documentation after an alleged abuse incident, and staff confirmed the absence of necessary documentation. Additionally, staff were unable to locate pharmacy reviews for two residents, indicating a failure to maintain proper documentation.
The facility did not maintain resident dignity by failing to cover foley drainage bags for two residents. One resident's uncovered bag was visible from the hallway, and another resident was observed with an uncovered bag while in a wheelchair. An LPN acknowledged that foley bags should be covered.
A facility failed to include a resident's advance directive in their medical record. A MOLST form was created and signed but was not filed in the electronic or paper chart, leaving it unavailable for nursing staff. The DON confirmed that without the form, the resident would be considered Full Code.
A facility failed to provide a completed bed hold policy notice to a resident before their transfer to a hospital. The notice was incomplete and lacked the resident's name and other details. An LPN stated the resident was drowsy and unable to sign, but this was not documented, and the notice was not given to the resident.
A facility failed to provide a baseline care plan summary to a resident within 48 hours of admission. The resident reported not being invited to a care plan meeting or receiving a baseline care plan summary. Interviews and medical record reviews confirmed the absence of the required documentation, and the staff could not provide evidence of compliance.
A resident reported receiving only two showers in a month, despite a preference for twice-weekly showers. The resident's concerns were communicated to the unit manager and DON, but the preferred schedule was not met. Task documentation showed inconsistencies and missing entries, and the nurse manager had not addressed the issue with the resident. The DON acknowledged the need for GNA reeducation on documentation.
A resident with respiratory conditions was receiving oxygen without a physician order, and the facility staff failed to administer the correct flow rate as prescribed. The resident's care plan did not address their respiratory needs, and staff were unaware of the correct oxygen flow rate, leading to inconsistencies in care. The facility's policy requires a physician order and a care plan for oxygen therapy, which were not in place.
The facility failed to monitor medications properly, resulting in an expired Influenza Vaccine Afluria Quadrivalent 5ml Multi-dose Vial being found in the 1st floor Unit 2 medication room. This was confirmed by a Unit Manager during an observation and interview.
A resident reported missing bottom dentures and difficulty eating without them. The facility failed to document the dentures upon admission and did not schedule a dental appointment or arrange transportation, despite agreeing to do so after a grievance was filed by the resident's family.
Failure to Develop and Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to ensure that comprehensive, person-centered care plans were developed and implemented to address residents' specific medical needs and significant changes in condition. One resident receiving oxygen therapy did not have this intervention included in their care plan, despite documentation in the Minimum Data Set (MDS) and direct observation of oxygen use. Additionally, the same resident had an active diagnosis of mood disorder and was prescribed risperidone, but neither the diagnosis nor the medication was addressed in the care plan. Another resident was admitted to hospice services following a significant change in condition, as indicated by physician orders and MDS documentation. However, there was no care plan addressing hospice or end-of-life care needs until several weeks after hospice admission, and only after the survey team arrived at the facility. Staff interviews confirmed that care plans should be updated promptly following significant changes in condition, but this did not occur in this case. A third resident, admitted for skilled rehabilitation and later transitioned to long-term care, did not have quarterly care plan meetings conducted as required. After the initial interdisciplinary care conference, there was no evidence of subsequent care plan meetings or documentation, despite ongoing concerns related to the resident's hearing and vision. The facility was unable to provide records of any additional care plan meetings after the initial conference.
Failure to Ensure Proper Medication Management and Documentation
Penalty
Summary
The facility failed to ensure proper management and documentation of controlled substances and medication administration according to physician orders. Surveyors observed that narcotic record books on multiple medication carts were missing required signatures from both incoming and outgoing nurses at shift changes. Several nurses confirmed that although narcotics were counted together, signatures were often omitted due to oversight or busy shifts. The Director of Nursing (DON) confirmed that both nurses are expected to sign the narcotic record book after each count, but this was not consistently done. A review of complaints and resident records revealed discrepancies in the documentation and administration of controlled substances. In one case, a resident's controlled drug administration record showed that oxycodone was removed from the narcotic supply on several occasions, but the Medication Administration Record (MAR) did not reflect that the medication was administered, despite the resident being cognitively intact at the time. Another complaint involved a resident who reported increased pain due to missed pain medication, and record review showed that pain medications were administered outside of the physician-ordered pain scale parameters, including both under- and over-medication, as well as administration when not clinically indicated. Further review of another resident's MAR showed that multiple medications, including antihypertensives and pain medications, were administered outside of the physician-ordered parameters, such as giving medications when blood pressure was below the specified threshold or administering pain medication for pain scores lower than required. Additionally, non-pharmacological interventions ordered to be offered prior to PRN medication administration were not documented as provided. These findings were confirmed through interviews with the DON and review of clinical records.
Incomplete Abuse Investigations and Documentation
Penalty
Summary
The facility failed to conduct thorough investigations and maintain proper documentation regarding allegations of resident abuse for four residents. In the case of Resident #424, the investigation lacked interviews with residents or staff and did not include signed statements. The Director of Nursing (DON) confirmed the absence of these documents and acknowledged the need for staff education. Similarly, for Resident #101, the investigation was incomplete as it did not include statements from the Geriatric Nursing Assistant (GNA) who reported the abuse or from the resident themselves. The Administrator noted that the incident occurred before the facility's change of ownership, and no additional documentation was available. For Resident #120, the facility could not provide a complete report of the incident involving an RN allegedly not stopping an enema when requested by the resident. The regional nurse indicated that older reports might be in storage, but the complete report was not retrieved by the survey's conclusion. Additionally, the investigation for Resident #99's physical abuse allegation was incomplete, lacking staff interviews, written statements, and a 5-day investigation result. The Administrator and Regional Nurse admitted the absence of a complete investigation file. These deficiencies were discussed with the administrative team at the exit conference.
Medication Administration Delays and Documentation Issues
Penalty
Summary
The facility failed to adhere to professional standards of nursing practice in administering medications to residents, as evidenced by multiple instances of delayed medication administration. Resident #60 reported not receiving medications on time, including PRN oxycodone, which was delayed until the next shift. The medication administration audit report confirmed that several medications scheduled for specific times were administered hours later than prescribed. Further investigation revealed that Resident #15's medication administration audit record showed multiple instances of late documentation, with some medications documented up to seven hours after administration. This practice violates the standard of nursing practice, which requires immediate documentation post-administration to ensure accurate records and prevent medication errors. Additional reviews of medication administration audit records for Residents #502, #509, and #102 demonstrated a pattern of late documentation and administration. For Resident #102, multiple doses of Tylenol were administered several hours after the scheduled time. These findings were discussed with the facility's administration team, highlighting a systemic issue with medication administration timing and documentation.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility staff failed to notify the state agency of an alleged case of abuse within the required 2-hour timeframe. This deficiency was identified during a survey when it was found that an incident involving alleged abuse occurred on 09/25/22 during the 3 pm to 11 pm shift, but was not reported to the state agency until 09/26/22 at 1 pm. The facility's policy mandates that all alleged violations involving abuse must be reported immediately, but no later than 2 hours after the allegation is made. The Administrator acknowledged the delay in reporting during an interview. Additionally, a resident reported verbal abuse by an agency RN to the DON, but the allegations were not reported to the state office or law enforcement within the required timeframe. The resident expressed feeling unsafe receiving medications from the nurse involved. The DON confirmed that the abuse allegations were not reported immediately as required, and the survey team was later provided with a copy of the initial report. These findings were discussed with the administration team at the time of the survey exit.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to ensure comprehensive care plans were developed and implemented for two residents, leading to deficiencies identified during a survey. Resident #112, who was admitted with Type 1 Diabetes Mellitus, did not have a diabetes care plan in place. Despite receiving insulin, there was no documented care plan addressing the resident's diabetes management, which is crucial for monitoring and adjusting treatment as needed. This oversight was noted during a review of the resident's medical record and was acknowledged by the Director of Nursing (DON) and Regional DON during an interview. Additionally, Resident #85, who had multiple diagnoses affecting respiratory function, including chronic obstructive pulmonary disease and emphysema, was not included in a care plan meeting and lacked a respiratory care plan. The absence of a care plan meant there were no documented goals or interventions to address the resident's respiratory needs, such as oxygen therapy. The facility's Oxygen Administration policy requires that care plans identify interventions for oxygen therapy, but this was not done for Resident #85, as revealed during a review of the resident's medical record and the facility's policy.
Failure to Follow Physician Orders for Residents
Penalty
Summary
The facility failed to adhere to physician orders for three residents, leading to deficiencies in care. Resident #40, who has multiple diagnoses including lymphedema and chronic kidney disease, was observed multiple times without the prescribed ACE wraps on their legs. Despite having clear physician orders to apply the wraps daily, the staff did not follow through, partly due to confusion over duplicate orders in the electronic health record (EHR) and a lack of access to the EHR by new staff. Resident #15 experienced issues with pain management due to the facility's failure to administer pain medication according to the physician's specified parameters. The medical record indicated that the resident was given incorrect dosages of Morphine Sulfate and Ibuprofen, which did not align with the pain scores documented. This discrepancy was noted over several instances, leading to the resident experiencing unmanaged pain. Resident #37 was observed receiving an incorrect oxygen flow rate, set at 3 liters per minute instead of the ordered 2 liters. This error was identified during a surveyor's observation and confirmed by the resident's assigned nurse. The nurse was unaware of the discrepancy until it was pointed out, indicating a lapse in monitoring and adherence to the physician's orders for oxygen therapy.
Failure to Document Abuse Allegation and Pharmacy Reviews
Penalty
Summary
The facility failed to document whether a resident exhibited signs and symptoms of abuse immediately following an allegation of abuse. This deficiency was identified during a review of Resident #508's medical record, which lacked evidence of documentation regarding the resident's condition after the alleged abuse. The Assistant Director of Nursing (ADON) confirmed the absence of a progress note or documentation that the physician was notified, although an x-ray was ordered two days after the alleged incident. The facility's policy requires thorough documentation of any changes in a resident's condition, but no such documentation was found for Resident #508. Additionally, the facility did not provide documentation to verify that monthly pharmacy reviews were completed for two residents, #11 and #21. During interviews, staff members, including an LPN Unit Manager and the Director of Nursing (DON), were unable to locate the pharmacy reviews for these residents. The DON mentioned that pharmacy reviews are printed and reviewed by the Medical Director, with copies kept in a binder in their office. However, no evidence of the pharmacy reviews for the specified residents was found, indicating a failure to maintain proper documentation as required.
Failure to Cover Foley Drainage Bags
Penalty
Summary
The facility failed to uphold the dignity of residents by not ensuring that foley drainage bags were covered. This deficiency was observed in two residents. During observation rounds, one resident was found with an uncovered foley catheter bag attached to their bed, visible from the hallway due to the open door. The bag contained amber-colored liquid. A Unit Manager LPN confirmed that foley bags should be covered. Another resident was seen in a wheelchair with an uncovered foley bag, also containing amber-colored liquid, while ambulating in the hallway.
Failure to Include Advance Directive in Resident's Medical Record
Penalty
Summary
The facility failed to ensure that a current copy of a resident's advance directive was included in the resident's medical record. This deficiency was identified during a record review and staff interviews, where it was found that a Medical Orders for Life-Sustaining Treatment (MOLST) form for a resident was not present in either the electronic or paper chart. The resident had been admitted to the facility, and the MOLST form was created and signed by a doctor but was left on the doctor's desk instead of being properly filed. As a result, the MOLST form was unavailable for nursing staff to reference from the time it was created until it was discovered missing during the survey. The Director of Nursing confirmed that without a MOLST or advance directive, the resident would be considered Full Code.
Failure to Provide Completed Bed Hold Policy Notice
Penalty
Summary
The facility failed to provide a completed bed hold policy notice to a resident prior to their transfer to a hospital. The deficiency was identified during a review of the medical records and staff interviews, which revealed that the resident was transferred to the hospital without receiving a copy of the bed hold policy. The notice was found in the resident's paper chart, but it was incomplete, lacking the resident's name and other necessary details. It was noted that the resident was their own representative, yet the notice indicated that the resident's son approved the bed hold policy via phone. An LPN involved in the process stated that the resident was drowsy and unable to sign the notice at the time of transfer, but this was not documented in the resident's chart. Additionally, the LPN admitted to not providing a copy of the notice to the resident before discharge.
Failure to Provide Baseline Care Plan Summary
Penalty
Summary
The facility failed to provide a baseline care plan summary to a resident within 48 hours of admission, as required. This deficiency was identified during a survey where it was found that a resident had not been invited to a care plan meeting nor received a baseline care plan summary. Interviews with the resident and the Director of Social Services confirmed the absence of a baseline care plan. Additionally, a review of the medical record did not reveal any documentation indicating that the resident was given a baseline care plan or summary. The nurses were unable to provide any progress notes or additional documentation to support that the baseline care plan was provided.
Failure to Provide Showers According to Resident Preference
Penalty
Summary
The facility failed to provide activities of daily living (ADLs), specifically showers, according to a resident's preference. The resident, who had recently moved from the first floor to the second floor, reported receiving only two showers in the past month, despite a preference for twice-weekly showers. The resident had communicated this concern to the unit manager and the Director of Nursing (DON) but did not receive the preferred frequency of showers. The resident also required a shower chair for assistance, which was not consistently provided. The surveyor's review of the electronic task documentation revealed inconsistencies and missing entries regarding the resident's shower schedule. The task form showed that the resident received showers on only three occasions during the month, with several dates left blank. The nurse manager had not recently spoken with the resident to address these concerns, and the DON acknowledged the need for reeducation of the geriatric nursing assistants (GNAs) on accurate documentation. This deficiency was discussed with the unit manager and the DON before the exit conference.
Failure to Provide Appropriate Respiratory Care
Penalty
Summary
The facility staff failed to provide appropriate respiratory care for a resident, as evidenced by the lack of a physician order for oxygen administration and the absence of a care plan addressing the resident's respiratory needs. The resident, who had diagnoses including chronic obstructive pulmonary disease, emphysema, atrial fibrillation, and atherosclerotic heart disease, was observed receiving oxygen at a flow rate of 2.5 liters per minute without a corresponding physician order in the electronic health record or paper chart. During the survey, it was noted that the resident continued to receive oxygen without a documented order, and the staff was unaware of the correct flow rate prescribed. An LPN initially stated the resident was on 3 liters of oxygen, but upon checking, realized the flow rate was 2.5 liters, which did not match any documented order. The LPN confirmed the absence of an oxygen order and notified the Unit Manager, who also acknowledged the lack of a physician order and was unsure of the reason for the oxygen administration. The Director of Nursing was informed of the findings and confirmed that a physician order should be in place for residents receiving oxygen. The facility's policy on oxygen administration requires a physician's order and a care plan outlining the interventions for oxygen therapy. Despite these requirements, the resident's care plan did not address their respiratory needs, and the staff failed to administer oxygen as prescribed, leading to inconsistencies in the oxygen flow rate provided to the resident.
Expired Vaccine Found in Medication Room
Penalty
Summary
The facility failed to properly monitor medications, as evidenced by the presence of an expired Influenza Vaccine Afluria Quadrivalent 5ml Multi-dose Vial in the 1st floor Unit 2 medication room. This deficiency was identified during observation rounds conducted at 03:05 PM, where surveyors found the expired vaccine. During a subsequent interview and observation with the Unit Manager, staff #6, at 03:15 PM, the staff member confirmed the presence of the expired vaccine, acknowledging the oversight in monitoring the medication's expiration date.
Failure to Arrange Dental Services and Transportation
Penalty
Summary
The facility staff failed to schedule a dental appointment and arrange transportation for a resident who reported missing bottom dentures. The resident could not recall the exact time or staff member to whom the incident was reported. Upon review, there was no documentation of the resident having dentures upon admission, and the resident expressed difficulty eating without them. The Director of Nursing (DON) confirmed that all residents' belongings are logged at admission, discharge, and readmissions, and a grievance form is completed for missing items. However, the resident's dentures were not listed on the personal inventory form. A grievance was filed by the resident's family member, who reported the missing dentures and was informed by the Director of Guest Services that the dentures were not documented upon admission. The family member planned to contact the insurance company for a replacement, and the facility agreed to schedule a dental appointment and cover transportation costs. Despite this agreement, the DON and Regional Nurse were unable to confirm that the dental appointment and transportation arrangements had been made, and there was no documentation to verify these actions were completed.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Lutherville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Autumn Lake Healthcare At Ruxton | 1.8 mi | — | 39 | 0 |
| Greater Baltimore Medical Center Sub Acute Unit | 2.2 mi | — | 0 | 0 |
| Chestnut Grn Hlth Ctr Blakehur | 2.3 mi | — | 13 | 0 |
| Pickersgill Retirement Community | 2.3 mi | — | 1 | 0 |
| Orchard Hill Rehabilitation And Healthcare Center | 2.9 mi | — | 16 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.