Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before 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 Autumn Lake Healthcare At Catonsville during CMS and state inspections, most recent first.
Surveyors found widespread sanitation and maintenance issues, including vermin droppings, debris, broken tiles, and poor cleaning practices in areas such as the kitchen, laundry, conference, and rehabilitation rooms. Pest management records showed repeated recommendations to address unsealed voids and improve sanitation, but these issues persisted across the facility.
Surveyors found that the facility did not maintain an effective pest control program, with repeated observations of vermin droppings, unsanitary conditions, and unaddressed recommendations from the pest management company. Evidence included pest activity in resident rooms and common areas, as well as a complaint where a mouse remained on a trap in a resident's room for an extended period before removal.
A resident's discharge MDS assessment was inaccurately completed, with errors including the omission of documented falls and incorrect reporting of a scheduled pain medication regimen, despite no evidence of scheduled pain medication administration.
A resident with peripheral vascular disease developed new wounds on both lower extremities, but staff failed to document wound size, characteristics, or changes in condition as required by facility policy. Despite orders for wound care and multiple assessments, documentation did not include necessary details to track wound progression or response to treatment.
A resident with significant cognitive impairment and a history of abnormal weight loss was not appropriately assessed for pain, despite having as-needed orders for Tylenol and Morphine. Staff failed to use a pain assessment tool suitable for the resident's cognitive status, and pain assessments were inconsistently documented or omitted, even when pain medication was administered. The facility's pain management policy requiring appropriate assessment and reassessment was not followed.
Two residents did not receive medications as ordered, with one resident's as-needed pain and anxiety medications not documented in the MAR despite being administered, and another resident's heart and pulmonary medications held without provider notification or documented parameters. The facility failed to ensure proper medication administration and documentation according to procedures.
Surveyors identified that the facility did not maintain accurate and complete medical records for two residents, including incomplete documentation of oxygen therapy and missing hospice visit notes after medication administration. Additionally, documentation for one resident was found misfiled in another resident's paper chart, including appointment and consultation forms. These deficiencies were confirmed through record review and staff interviews, including with the DON and RN.
Sanitation and Vermin Control Deficiencies Identified Facility-Wide
Penalty
Summary
Surveyors identified multiple sanitation and maintenance deficiencies throughout the facility, including the presence of vermin droppings in the conference room, kitchen, and rehabilitation department. Observations revealed accumulated debris, food remnants, and water under kitchen equipment, as well as broken tiles and voids in the kitchen and laundry areas. Pest management company records indicated repeated recommendations to seal voids and improve sanitation, with documentation of ongoing issues such as unsealed holes and poor cleaning practices. The ice machine room was found with a wall void stuffed with steel wool, a wet dirty towel under the machine, and debris on the floor. Further inspection of the laundry area revealed rusted, broken metal trim with holes, broken tiles, a leaking sink with a bucket collecting drips, and accumulated lint and debris. The clean laundry room contained a dried spill, bottle cap, wrapper, and a shoe behind a linen cart. In the rehabilitation department, vermin droppings, a pistachio nut, and various debris were observed under the AC unit. These findings collectively demonstrate a failure to maintain a sanitary environment in multiple areas of the facility.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by repeated observations of vermin droppings, debris, and unsanitary conditions in multiple areas, including the conference room, kitchen, laundry area, and rehabilitation department. Surveyors noted that recommendations from the pest management company were not consistently followed, such as the need to utilize pest log books, seal voids and holes, and improve sanitation procedures. Despite weekly visits from the pest management company, the same issues were repeatedly documented in treatment reports, including unsealed voids in the kitchen, broken tiles holding dirty water, and poor sanitation in food preparation and dishwashing areas. During the investigation, surveyors observed multiple instances of pest activity and unsanitary conditions, such as vermin droppings under kitchen equipment, food debris, water accumulation, and broken or rusted building materials. In the laundry and rehabilitation areas, additional evidence of pest activity and poor housekeeping was found, including mouse droppings, lint buildup, and various debris. These findings were corroborated by pest management service reports, which documented ongoing mice activity and the need for improved facility practices. A specific complaint was also investigated, in which a resident's family reported that a mouse remained on a trap in the resident's room for 10 hours before removal. The pest management company’s inspection reports confirmed the presence of mice and other pests in resident rooms and common areas during their weekly visits. Facility leadership acknowledged the surveyors' findings and the ongoing pest issues, but no additional information was provided to demonstrate that an effective pest control program was in place.
Inaccurate MDS Assessment Documentation for Discharge
Penalty
Summary
The facility failed to accurately document a discharge Minimum Data Set (MDS) assessment for a resident who was admitted as a hospice respite patient. Record review showed that the resident experienced two falls, as documented in progress notes, and was assessed for injury on both occasions. However, the discharge MDS assessment incorrectly indicated that the resident had not experienced any falls since admission, which was later confirmed as an error by the MDS Coordinator. Additionally, the resident had orders for two pain medications, Tylenol and Morphine, both prescribed on an as-needed basis. Review of the Medication Administration Record (MAR) revealed no documentation that either medication was administered. Despite this, the discharge MDS assessment inaccurately documented that the resident was on a scheduled pain medication regimen. The MDS Coordinator confirmed that this was also a documentation error.
Failure to Document Wound Assessments and Responses to Treatment
Penalty
Summary
The facility failed to adequately document wounds and responses to treatment for a resident with a history of peripheral vascular disease and foot pain. A change in condition was identified when a new open wound appeared on the resident's left lower extremity, and a skin assessment was performed. However, the assessment did not include documentation of the wound's size or characteristics. An order for wound care was written, but subsequent skin assessments continued to lack detailed documentation regarding the wound's measurements or characteristics. Further changes in the resident's condition were noted, including the development of a new wound on the right leg, with descriptions of wet dressings, foul odor, and significant pain. Both lower extremities were found to have soaked dressings with serosanguinous drainage and foul odor, and the right second toe was noted to have drainage and black discoloration. Despite these findings, the facility's documentation did not meet its own policy requirements for complete wound assessment, which include type, stage, measurement, and description of wound characteristics.
Failure to Use Appropriate Pain Assessment for Cognitively Impaired Resident
Penalty
Summary
Facility staff failed to utilize an appropriate pain assessment tool based on a resident's cognitive status. The resident in question had a history of abnormal weight loss and senile degeneration of the brain, was admitted as a hospice respite patient, and was documented as being very confused and not easily redirected. Despite having as-needed orders for Tylenol and Morphine for pain, there was no documentation indicating administration of Tylenol or Morphine on the MARs, and the pain monitoring documentation lacked clarity regarding the basis for the recorded pain assessment numbers. Pain assessments were inconsistently completed, with one assessment noting multiple pain indicators but then indicating the resident could not communicate pain location or characteristics. Subsequent assessments inappropriately skipped staff assessment for pain, despite the resident's inability to communicate effectively. Review of the facility's pain management policy revealed that staff were required to use a pain assessment tool appropriate for the resident's cognitive status and to reassess pain management at established intervals. However, when Morphine was administered, there was no evidence that a pain assessment was completed before or after administration to evaluate effectiveness, as confirmed by the ADON. No additional pain assessments were provided to the surveyor, and the documentation did not support that pain was being adequately assessed or managed for this resident.
Failure to Accurately Document and Administer Medications
Penalty
Summary
The facility failed to ensure accurate documentation and administration of medications for two residents. For one resident admitted as a hospice respite patient, there were orders for as-needed pain and anxiety medications, including Tylenol, Morphine, and Lorazepam. Although the controlled drug administration records and hospice notes indicated that these medications were administered, there was no corresponding documentation in the resident's Medication Administration Record (MAR). The Assistant Director of Nursing confirmed that all controlled medications taken should be signed out in both the controlled log book and the MAR, but this was not done. For another resident with a history of hypertension, cardiomyopathy, congestive heart failure, pulmonary hypertension, and atrial fibrillation, the MAR showed that several medications were not administered as ordered and were coded with reasons such as vital signs out of parameters or other notes, despite no such parameters being specified in the medication orders. Some medications were also not given due to awaiting delivery or order issues. The Regional Director of Nursing stated that medications were held based on nursing judgment, but could not confirm if the provider was notified when medications were withheld. The attending physician stated that he would expect to be notified if medications were not administered as ordered, especially when coordinated with specialists.
Failure to Maintain Accurate and Complete Medical Records
Penalty
Summary
The facility failed to maintain medical records in accordance with accepted professional standards by not ensuring complete and accurate documentation and by misfiling documents. For one resident with a history of acute respiratory failure, sleep apnea, and thrombotic pulmonary embolism, there was a physician order for continuous oxygen therapy. However, for 21 out of 28 days, the vital sign documentation indicated that oxygen saturation readings were taken while the resident was on room air, despite the order for continuous oxygen. The Director of Nursing confirmed that this documentation was erroneous after speaking with the nursing staff. In another case, a hospice respite resident's medical record did not contain documentation of a hospice staff visit, during which medications were administered for comfort following a fall, even though the hospice provider confirmed the visit and interventions took place. Additionally, during a review of a resident's paper medical record, documentation belonging to a different resident was found misfiled in the chart. The misfiled documents included an appointment slip, a transportation form, and a consultation note. The error was recognized by a registered nurse when returning the documents to the chart, and the issue was reported to the Regional Director of Nursing, who acknowledged that the documents had been filed in the wrong chart.
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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 Catonsville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Forest Haven Nursing And Rehabilitation Ctr | 0.2 mi | — | 54 | 0 |
| Autumn Lake Healthcare At Summit Park | 0.9 mi | — | 0 | 0 |
| Ridgeway Rehab Center | 1.1 mi | — | 28 | 0 |
| Frederick Villa Healthcare | 1.1 mi | — | 16 | 0 |
| St. Joseph's Nursing Home | 1.1 mi | — | 17 | 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.