Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around December 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 Loch Raven during CMS and state inspections, most recent first.
Facility staff did not ensure that 2nd floor residents who could not use stairs were able to receive visitors when the only elevator was out of service for an extended period. Complaints indicated that some family members, who were themselves unable to ambulate stairs, could not visit their relatives on the 2nd floor during this time. The emergency plan directed non-ambulatory 2nd floor residents to remain on that floor unless there was an emergency and did not address how visitation would be maintained when the elevator was inoperable. The Administrator reported that visitors could use the stairs and that an emergency chair system could be used to move residents, but also stated that the chair system was not used for visitation and was unaware of any complaints, despite two having been filed.
Facility staff did not complete required quarterly smoking safety assessments for several residents identified as smokers, including some who had not been reassessed for many months and one who had never been assessed during their stay. This issue was discovered during a complaint survey after the facility’s only elevator was out of service for an extended period, affecting a group of residents on an upper floor who needed to reach a designated smoking area on a lower floor. Review of records and staff interviews, including with the DON and a unit manager, confirmed that the facility’s own practice of quarterly smoking safety assessments for smokers was not followed for half of the affected residents.
Staff failed to conduct complete investigations into two residents’ abuse allegations. In one case, a resident reported that an employee poked their face and made an obscene gesture, but the investigation lacked a statement from the corporate representative who was first notified of the allegation. In another case, a resident reported that someone in blue clothing put a hand by their face and over their mouth, with a specific GNA identified as the alleged perpetrator; however, the investigation did not include statements from two GNAs who were on duty on the unit at the time of the alleged incident, despite leadership having the opportunity to ensure all relevant documents were present.
Staff failed to create person-centered care plans for two residents, one with mobility limitations and one receiving peritoneal dialysis. For the resident with mobility issues, the care plan did not address the resident’s refusal to use a Hoyer lift and preference for pivot transfers, despite therapy prohibiting pivot transfers and staff awareness of the resident’s resistance. For the resident on peritoneal dialysis, the care plan did not specify that the treatment was peritoneal dialysis, nor did it include the treatment schedule or cycle time frames; an LPN Unit Manager acknowledged using a generalized renal care plan without incorporating the specific dialysis prescription.
A resident’s medical record lacked documentation confirming that scheduled showers or bed baths were provided on multiple dates, and there was also no record of any refusals of care on those days. The DON and an LPN unit manager reported that showers were scheduled on specific shifts and that completed showers and refusals should be documented on shower/skin sheets and in the care plan, but the surveyor found gaps where no such entries existed. This resulted in incomplete ADL documentation and failure to maintain medical records according to accepted professional standards.
Staff failed to include the unit census on daily nurse staffing/assignment sheets, with 19 of 19 reviewed sheets missing this information. When a surveyor reviewed staffing records to determine which staff were working during an alleged abuse incident on one unit, the census was not documented for that shift or for multiple subsequent days across all three shifts. A scheduling manager reported not knowing who was responsible for completing the assignment sheets or that census data was required, and the DON stated they had not previously been told that the census needed to be included on the assignment sheets.
Staff did not adhere to a physician's order specifying that an opioid pain medication be administered only for pain levels of 7-10, instead giving the medication to a resident on multiple occasions when pain scores were documented as lower or not provided. An LPN acknowledged awareness of the order but still administered the medication outside the prescribed parameters, and the DON confirmed staff expectations regarding pain assessment and medication administration.
Surveyors found that two residents were not receiving oxygen therapy according to physician orders, with staff unaware of the correct flow rates and not checking flow meters as required. Additionally, a resident with complex medical needs experienced vomiting and lethargy, but the nurse failed to perform a thorough assessment, obtain vital signs or blood sugar, or notify a practitioner before sending the resident to the hospital. Staff interviews confirmed that protocols for monitoring and response were not followed.
The facility failed to provide timely wound care and consistent turning and repositioning for two residents with pressure ulcers. Staff delayed initiating ordered wound treatments for a new admission and did not consistently document or perform required wound care and repositioning for another resident, as confirmed by the DON.
Failure to Ensure Visitation Rights During Elevator Outage
Penalty
Summary
Facility staff failed to ensure that residents residing on the 2nd floor who could not safely ambulate using stairs were able to exercise their right to have visitors when the facility’s only elevator malfunctioned. Complaint reviews showed that family members were unable to visit their relatives on the 2nd floor when the elevator was inoperative, and these family members themselves were unable to use the stairs. An incident report documented that the facility’s only elevator was malfunctioning for an extended period, from 3/28/26 to 4/23/26. During this time, residents who could not use the stairs remained on the 2nd floor, and some of their family members could not access them due to the lack of elevator service. Review of the facility’s emergency plan revealed that it instructed that 2nd floor residents who could not safely use the stairs should remain on the 2nd floor unless there was an emergency, and it did not include any provisions for maintaining visitation when the elevator was inoperable. In an interview, the Administrator stated that visitors could use the stairs to visit 2nd floor residents and that residents could be transported using an emergency chair system to meet visitors who could not use the stairs. However, the Administrator acknowledged that the emergency chair system was not used for visitation purposes during the elevator outage and reported being unaware of any complaints about the inoperative elevator, despite two complaints having been received by OHCQ. No additional documentation was provided to show a plan to support visitation for 2nd floor residents during the elevator malfunction.
Failure to Complete Required Quarterly Smoking Safety Assessments
Penalty
Summary
Facility staff failed to update smoking safety assessments at least once every three months for multiple residents identified as smokers. During a complaint survey focused on smoking safety, surveyors reviewed an incident involving the facility’s only elevator being inoperative for nearly a month, which affected residents who lived on the 2nd floor and needed to access the 1st-floor smoking area. The facility’s investigation identified a group of 10 residents on the 2nd floor who smoked and required additional accommodations to safely ambulate to the designated smoking area. Review of these residents’ medical records showed that 5 of the 10 did not receive quarterly smoking safety assessments as required by the facility’s practice. Specifically, four residents had not received a smoking assessment since May 2025, and one resident had no documented smoking assessment at any time during their stay. During interviews, the Unit Manager stated that residents identified as smokers are to be assessed quarterly for smoking safety. When the surveyor pointed out the missing assessments, the DON reviewed the records and confirmed that these residents had not received the required quarterly smoking assessments. This lack of timely reassessment occurred in the context of an extended elevator outage that necessitated special consideration for safe smoking access for residents residing on the 2nd floor.
Incomplete Investigations of Resident Abuse Allegations
Penalty
Summary
Facility staff failed to complete thorough investigations of two separate resident allegations that were reported to the state agency. For the first incident, a resident alleged that on a specific date and time an employee poked two fingers into their face and showed them their middle finger. The five-day follow-up documented the allegation, but the investigation file did not clearly identify who was the first point of contact for the report. During interview, the Administrator stated that a corporate representative was initially made aware of the alleged incident, but there was no statement from this corporate representative included in the investigation file. The Administrator described their usual investigation process as interviewing involved parties, identifying and interviewing witnesses, reviewing staffing for the date of the alleged incident, and interviewing the resident’s roommate and other nearby residents if there were no direct witnesses. In the second incident, a resident reported that during a specific shift someone wearing blue put a hand by their face and over their mouth, and a particular GNA was identified as the alleged perpetrator. Review of the staffing sheet for the time of the alleged incident showed that two GNAs were working on the unit where the incident was reported to have occurred. However, the investigation file contained no statements or interviews from these two GNAs. Prior to the surveyor’s review of the investigation, the DON and a regional nurse were given the opportunity to review the investigation to ensure all necessary documents were available, yet the statements from the two GNAs remained absent. These omissions demonstrated that the facility did not conduct complete investigations into the reported allegations.
Failure to Develop Person-Centered Care Plans for Mobility and Peritoneal Dialysis Needs
Penalty
Summary
Facility staff failed to develop and implement person-centered care plans that addressed all identified needs for two residents, one with mobility limitations and one receiving peritoneal dialysis. For the resident with mobility limitations, the care plan included interventions for resistance to care and adjustment issues, but did not address the resident’s specific resistance to use of a Hoyer lift and the resident’s insistence on pivot transfers from bed to wheelchair. The Unit Manager confirmed that the resident was resistant to care, did not like the Hoyer lift, and preferred pivot transfers, but also stated that physical therapy had prohibited pivot transfers. Despite this known conflict between the resident’s preferences and therapy restrictions, the care plan lacked individualized interventions related to the resident’s resistance to the Hoyer lift and continued request for pivot transfers. For the resident receiving peritoneal dialysis, review of the electronic health record showed an order for peritoneal dialysis, but the resident’s care plans did not include a person-centered care plan specific to this treatment. The existing dialysis care plan did not specify the type of dialysis treatment being provided, did not document when the resident was scheduled to receive the treatment, and did not include time frames for the dialysis cycles. During an interview, the LPN Unit Manager stated that they do not place the dialysis prescription details into the care plan and instead use a generalized renal care plan by selecting standard items, confirming that the care plan was not individualized to the resident’s ordered peritoneal dialysis regimen.
Failure to Document Resident Showers and Refusals
Penalty
Summary
Facility staff failed to maintain complete and accurate documentation of bathing care for a resident, specifically regarding showers and refusals of showers. During a complaint survey, the surveyor requested verification that Resident #5 was receiving scheduled showers. The DON stated that the resident was scheduled for showers on the 3 pm–11 pm shift on Tuesdays and Fridays, and provided shower sheets for several dates in October and early November. However, there was no documentation to verify that the resident received a shower or bed bath on 10/17/25, 10/21/25, and 10/24/25. The DON explained that when a resident receives a shower it is documented on a skin sheet, and that refusals of showers should be documented both in the plan of care and on the shower sheet. Despite this, the surveyor did not receive any documentation indicating that the resident either received bathing care or refused showers on the missing dates. This lack of documentation showed that the facility did not safeguard resident-identifiable information and maintain medical records in accordance with accepted professional standards, as there was no record confirming whether the resident’s scheduled showers or refusals occurred on the identified dates.
Failure to Include Unit Census on Daily Nurse Staffing Sheets
Penalty
Summary
Facility staff failed to include the unit census on daily nurse staffing/assignment sheets, as identified in 19 of 19 staffing sheets reviewed during a complaint survey. On review of the Unit 2 staffing sheet for the 3:00 pm–11:00 pm shift on 12/03/25, the census field was blank, and the surveyor was using this sheet to determine which staff were working during an alleged abuse incident. Further review of Unit 2 staffing sheets dated 12/04/25 through 12/09/25 for all three shifts (7:00 am–3:00 pm, 3:00 pm–11:00 pm, and 11:00 pm–7:00 am) showed that none of these assignment sheets included the census. During an interview, the Scheduling Manager stated they were unsure who was responsible for completing the assignment sheets on the units and were not aware that the census needed to be included. The DON stated that during the previous survey they had not been informed that the census needed to be included on the assignment sheet. No specific resident medical histories or conditions were described in the report, and the deficiency centers on incomplete staffing documentation and lack of clarity regarding responsibility for completing census information on assignment sheets.
Failure to Follow Physician's Order for Pain Medication Administration
Penalty
Summary
Facility staff failed to follow a physician's order regarding pain management for a resident. The medical record review showed that the resident was prescribed an opioid 10 mg to be administered as needed every 4 hours, but only for pain levels rated between 7 and 10. Despite this, staff administered the medication on multiple occasions when the resident's documented pain level was below 7, including several instances where the pain level was recorded as 0 or 6, and once as low as 4. These deviations from the prescribed parameters were documented in the medication administration record for both May and June. During interviews, an LPN acknowledged awareness of the physician's order to administer the medication only for pain levels of 7-10 but admitted to giving the medication when the resident either did not provide a pain score or when a lower pain score was documented. The LPN also confirmed that no pain assessment was documented in the progress notes for these instances. The DON confirmed that staff were expected to assess and document the resident's pain level and administer medication according to the physician's parameters, acknowledging the concern when presented with the findings.
Failure to Follow Physician Orders for Oxygen Therapy and Inadequate Response to Change in Condition
Penalty
Summary
Surveyor observations, medical record reviews, and staff interviews revealed that the facility failed to follow physician orders for oxygen therapy for two residents. One resident was observed receiving oxygen at 3.5 liters per minute (LPM) when the physician's order specified 2 LPM, and another was receiving 2.5 LPM instead of the ordered 2 LPM. Nursing staff were unaware of the correct flow rates and reported checking oxygen flow meters only weekly or every other day, rather than every shift as required by the orders. Staff were unable to state when the oxygen flow rates were last checked, and adjustments were only made after surveyor intervention. Additionally, the facility failed to appropriately assess and report a change in condition for a resident with multiple complex medical issues, including end-stage renal disease, diabetes, and a sacral pressure ulcer. The resident reported vomiting multiple times, but there was no evidence of a thorough assessment or notification to a practitioner at that time. Later, when the resident was found lethargic, the nurse did not obtain vital signs or a blood sugar level before sending the resident to the hospital. Documentation of the change in condition was incomplete, and the nurse did not fully assess the resident prior to transfer. Interviews with facility staff confirmed that the expected protocols for monitoring oxygen therapy and responding to changes in resident condition were not followed. The DON acknowledged that nurses would not have known the correct oxygen flow rates if checks were only performed weekly, and the unit manager stated that a full assessment and practitioner notification should have occurred for the resident with vomiting and lethargy. The nurse involved in the change in condition incident was an agency nurse and was unavailable for interview.
Failure to Provide and Document Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to provide timely and appropriate pressure ulcer care for two residents. For one newly admitted resident with a sacral pressure ulcer, staff did not initiate the physician-ordered wound care regimen until two days after admission, despite documentation of the wound on the admission assessment and a standing order for daily treatment. The resident was later sent to the hospital with worsening wounds and a diagnosis of sepsis. Additionally, recommended diagnostic tests by a wound specialist were not completed before the resident's transfer to the hospital. For another resident, the facility did not consistently document or provide daily wound care and failed to ensure regular turning and repositioning as ordered. Multiple instances were identified where wound care was not documented in the treatment administration record, and several shifts lacked documentation of turning and repositioning. The DON confirmed that staff are expected to document wound care and repositioning, but acknowledged the missing documentation and lapses in care.
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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 Baltimore
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Autumn Lake Healthcare At Parkville | 0 mi | — | 0 | 0 |
| Autumn Lake Healthcare At Perring Parkway | 1.7 mi | — | 17 | 0 |
| Towson Rehabilitation And Healthcare Center | 1.9 mi | — | 18 | 0 |
| Edenwald | 2.2 mi | — | 3 | 0 |
| Holly Hill Healthcare Center | 2.7 mi | — | 0 | 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.