Above average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Autumn Lake Healthcare At Cherry Lane during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and significant medical history was care planned as needing assistance with ADLs and being dependent for mobility, but the care plan was not updated to specify the current transfer level after PT documented that the resident required maximal assistance of one person and could perform most of the transfer activity. Floor staff, including an LPN and a GNA, continued to use a mechanical lift with two staff for transfers, and the resident and attending physician both described ongoing lift use. The MDS coordinator acknowledged the resident had improved and that the facility was behind on updating care plans, while the Rehab Director reported communicating functional changes in morning meetings but not participating in care plan or Kardex updates and was unaware staff still used the lift. The DON stated that care plans were expected to be current and revised timely, but this had not occurred for this resident’s transfer and mobility needs.
A resident with spinal stenosis, a lumbar compression fracture, and moderate cognitive impairment was care planned as dependent on two staff and a mechanical lift for transfers, even after PT documented that the resident could perform most of the transfer with only one-person, weight-bearing assistance. The resident’s spouse and a GNA reported that the resident could stand with staff help and no longer required a mechanical lift, but the comprehensive care plan was not revised to reflect these current transfer needs. The MDS coordinator acknowledged the facility was behind on updating care plans and could not explain the lack of revision despite IDT discussions, while leadership stated they expected timely, accurate care plan updates and effective staff communication.
Failure to Maintain Resident Privacy: A resident shared a room with another resident when staff entered without proper notice or invitation. A GNA was observed leaving the room without the resident's awareness, the curtain was open, and another GNA quickly entered after a rapid knock and went into the bathroom to wash hands. The DON stated staff are expected to knock and wait before entering and to close the curtains if providing care.
Failure to timely report abuse allegations to the State agency was identified for two residents. Visitors reported witnessing an aide forcefully push one resident back into a chair and restrain the resident with a bedside table, and a separate resident raised a concern about an aide’s threatening response during breakfast service. The NHA and DON acknowledged the allegations were not reported as abuse, relied on staff denials, and did not report the investigation results within the required timeframe.
A resident’s discharge MDS was coded as a transfer to a short term general hospital, but the clinical record showed the resident died in the facility. The MDS Coordinator confirmed the discharge status was coded inaccurately.
Failure to complete annual GNA performance appraisals. Review of an employee file showed that GNA #18 had only one documented appraisal in the record, with no evidence of annual reviews before or after that entry. The Administrator confirmed the appraisals had not been completed at least annually from hire, and no additional documentation was provided at exit.
Failure to Monitor Side Effects of Psychotropic Medication: A resident with dementia, MDD, and DM was receiving Seroquel for dementia, but the MAR/TAR did not show monitoring for side effects despite a care plan intervention to monitor and document them. The UM confirmed the resident was not being monitored, and the record later showed a physician order for side-effect monitoring was added after surveyor review.
Unsecured Medication Cart and Unlabeled Opened Medications: During rounds on the 1st Floor A wing, the surveyor found a medication cart left open and unattended. Inside were opened bottles of Acetaminophen 325 mg, Acetaminophen 500 mg, and Stool Softener 100 mg, and none had dates showing when they were opened. An RN confirmed the cart should remain locked and opened meds must be dated.
Improper Food Labeling and Storage: Surveyors found multiple opened food items in the kitchen freezer without opening or expiration dates, and undated or unlabeled resident foods in 2 nutrition room refrigerators. One refrigerator also contained expired yogurt and skim milk, along with several tied bags and containers of food lacking resident ID or dates. Staff confirmed the items should have been labeled and dated per facility policy.
Infection control practices were not followed for a resident with dementia who was dependent on staff for dressing, grooming, and personal hygiene. A pair of name-marked shoes was observed on the bedside table next to an unopened apple juice, and a GNA said she did not place the shoes there. A Charge Nurse stated the shoes should have been in the closet.
Failure to reoffer pneumonia vaccinations: Two residents had documentation showing the pneumonia vaccine was previously offered and refused, but there was no record that it was offered again while they remained in the facility. The IP confirmed the EMR and paper charts did not show additional offers, and the DON stated residents who refuse the vaccine should be offered it again in the future.
Failure to Maintain Current, Person-Centered Transfer Care Plan
Penalty
Summary
The deficiency involves the facility’s failure to develop and maintain a comprehensive, person-centered care plan that accurately specified the level of assistance required for a resident’s transfers and mobility. The resident, admitted with anoxic brain injury, epilepsy, and cardiomyopathy, had a BIMS score of 6 indicating severe cognitive impairment and was coded on the MDS as dependent on staff for transfers. The care plan, initiated at admission, broadly indicated the resident needed assistance with ADLs related to decreased mobility and acute intracranial processes and stated the resident was dependent on staff for mobility/locomotion on and off the unit, but it did not clearly specify the current transfer status or level of assistance required. A PT discharge summary later documented that the resident required minimal assistance of one person for transfers and could perform 75% or more of the activity with weight-bearing assistance from one caregiver. Despite this therapy documentation, interviews showed that floor staff, including an LPN and a GNA, consistently used a mechanical lift with two staff to transfer the resident and reported that the resident did not get out of bed independently. The resident also reported that two staff used a lift to get them out of bed after bathing. The attending physician stated the family needed training on use of the lift in preparation for discharge, indicating ongoing use of the lift. The MDS Coordinator acknowledged the resident had been admitted using a mechanical lift, had improved, and that staff sometimes still used the lift, and further stated the facility was behind on updating care plans. The DON and Rehabilitation Director described a process where therapy communicated functional status changes during morning meetings, but the Rehabilitation Director stated she did not participate in care plan or Kardex updates and was unaware staff continued to use the mechanical lift despite the therapy discharge summary indicating maximal assistance of one person. The DON later stated she expected care plans to be current and revised timely, underscoring that the resident’s care plan had not been updated to reflect the resident’s current transfer needs.
Failure to Update Care Plan for Changed Transfer Needs
Penalty
Summary
The deficiency involves the facility’s failure to revise a resident’s comprehensive, person-centered care plan to reflect current transfer needs. The resident was admitted with spinal stenosis and a wedge compression fracture of the first lumbar vertebra and had moderate cognitive impairment, with an MDS indicating a need for partial/moderate assistance for transfers. The care plan, initiated shortly after admission, directed staff to use a mechanical lift with two staff for transfers due to assistance needs with activities of daily living related to the spinal compression fracture and dementia. However, a PT discharge summary later documented that the resident required only a minimum of one person for transfers, could perform 75% or more of the transfer activity, and needed only weight-bearing assistance from one caregiver. Despite this documented improvement, the care plan was not updated to reflect the resident’s current transfer status. The resident’s spouse reported that the resident could stand with staff assistance and transfer out of bed, and a Geriatric Nursing Assistant stated the resident did not require a mechanical lift for transfers. The MDS Coordinator acknowledged that the facility was behind on updating residents’ care plans and could not explain why this resident’s care plan had not been revised, even though transfers were discussed in morning Interdisciplinary Team meetings. The DON stated she expected care plans to be current and revised timely and accurately so staff would know the expected care, and the Administrator stated that staff communication was key so that residents’ care plans would be updated and revised in a timely manner.
Failure to Maintain Resident Privacy
Penalty
Summary
The facility failed to maintain a resident's right to privacy for one resident observed for privacy. During an observation of the room shared by Resident #137 and Resident #22, Resident #137 was in the window bed and Resident #22 was lying near the door with eyes closed, while no staff members were in the room. When Resident #137 began expressing concerns during an interview, the resident was asked if the door should be shut and replied yes. At that time, GNA #19 was observed leaving the room from the side of Resident #22's bed, and the curtain was open. Resident #22 remained lying in bed with eyes closed, and there had been no notification that GNA #19 had entered the room. During the continued interview, GNA #20 made a rapid knock on the closed door and quickly walked in without pausing or waiting for an invitation, then went into the bathroom and washed her hands. She stated she had entered to wash her hands after taking trays to the kitchen. GNA #19 later stated she was not assigned to the room and had entered because she was looking for towels. The DON stated the expectation was to knock and wait before entering a resident's room and to close the curtains if providing care.
Failure to Timely Report Abuse Allegations
Penalty
Summary
The facility failed to timely report allegations of abuse to the State agency and failed to report the results of its investigations within 5 working days for 2 of 2 abuse allegations identified during the complaint survey. In one allegation, two separate visitors reported witnessing GNA #2 forcefully and aggressively push Resident #158 back into a chair in the dining room and then restrain the resident with a bedside table. Both complainants stated they reported their concerns to nursing staff and Administration and continued to follow up without receiving answers. During interview, the NHA and DON acknowledged they did not report the allegation to the State agency, stating they did not think it was a self-report because it was not reported to them as abuse, and the DON said she interviewed the GNA, who denied the event occurred as reported. A second allegation involved Resident #72, who raised a concern in resident council meeting minutes about an aide delivering a breakfast tray and reportedly telling the resident, "bring it on." The DON stated the resident had behaviors and did not consider the concern reportable after speaking with the GNA, who denied the event as described. The resident council concern form showed the action taken was to speak with other residents and the GNA, but the facility again did not report the allegation to the State agency and did not implement documented safety interventions during the investigation. The surveyor reviewed these concerns with the DON and Administrator, who questioned whether every allegation from a resident with behaviors had to be reported.
Inaccurate MDS Discharge Status Coding
Penalty
Summary
Facility staff failed to accurately code a resident’s discharge status on the Minimum Data Set (MDS) assessment. Resident #152 had a discharge MDS completed on 5/21/2025, and Section A2105 (Discharge Status) was coded as discharged to a short term general hospital. However, review of the clinical record showed a discharge summary stating that Resident #152 passed away in the facility. During interview, the MDS Coordinator confirmed that Resident #152 was a death in the facility and that the discharge status had been coded inaccurately.
Failure to Complete Annual GNA Performance Appraisals
Penalty
Summary
The facility failed to complete annual performance reviews for Geriatric Nursing Assistants (GNAs), identified for GNA #18 during the annual survey. Review of the employee personnel file on 08/07/2025 showed that GNA #18 was hired on 06/18/2014 and had a performance appraisal completed on 06/18/2017, but there was no evidence of performance appraisals completed before or after that date. The report states that performance appraisals are to be completed at least every 12 months to identify in-service education needed to address GNA competencies. During an interview on 08/07/2025 at 2:35 PM, the Administrator confirmed that GNA #18's performance appraisals had not been completed at least annually from the date of hire, and no additional documentation was provided at exit to show annual completion.
Failure to Monitor Side Effects of Psychotropic Medication
Penalty
Summary
The facility failed to provide adequate monitoring of a resident receiving psychotropic medication for side effects. Resident #2 was admitted with diagnoses including dementia, major depressive disorder, and diabetes mellitus, and was receiving Seroquel 125 mg daily at bedtime for dementia. The resident’s care plan included an intervention to administer medications as ordered and to monitor and document side effects and effectiveness, but review of the MAR and TAR did not show evidence that the resident was being monitored for side effects of Seroquel. During interview, the Unit Manager stated that residents receiving psychotropic medications are monitored for side effects and that the results are documented on the MAR or TAR. After reviewing the resident’s record, the Unit Manager confirmed that Resident #2 was not being monitored for side effects of Seroquel. The record later showed that a physician order to monitor for side effects was initiated after the surveyor’s intervention, with monitoring beginning on the same day the order was written.
Unsecured Medication Cart and Unlabeled Opened Medications
Penalty
Summary
Drugs and biologicals were not properly labeled and stored in accordance with accepted professional principles. During environmental rounds on the 1st Floor A wing, the surveyor observed a medication cart left open and unattended. Inside the cart were one bottle of Acetaminophen 325 mg, one bottle of Acetaminophen 500 mg, and one bottle of Stool Softener 100 mg, and all three bottles were opened without documented dates showing when they were initially opened. RN #5 stated that the medication cart is expected to remain locked at all times and that opened medications must be labeled with the date they are opened, and RN #5 confirmed that the cart had been left unlocked and the medications were not labeled with opening dates.
Improper Food Labeling and Storage
Penalty
Summary
Food was not stored in accordance with professional standards in the kitchen and in 2 of 4 nutrition rooms. During an initial tour of the kitchen, surveyors found multiple opened food items in the walk-in freezer with no labels showing opening or expiration dates, including chocolate chip cookies, Charbroil patties for Salisbury, Salisbury steaks, tilapia fillets, an additional bag of Salisbury steaks/burgers, and frozen cookie dough. The kitchen staff member interviewed stated the items were supposed to be labeled after opening with opening and expiration dates, and the Food Service Director confirmed that all items should have been labeled after opening. The facility policy reviewed stated that all foods stored in the refrigerator or freezer will be covered, labeled, and dated with a use-by date. In the 2A/2B nutrition room refrigerator, surveyors found undated and unlabeled food stored for residents, including a plastic container with unknown food for one resident, a tied plastic bag of food for another resident, and a blue lunch bag with food that had no resident identification or dates. In the 1A/1B nourishment room refrigerator, surveyors found expired and unlabeled food, including yogurt that expired June 14, 2025, skim milk for a resident that expired July 8, 2025, and several tied bags and containers of food with no dates or resident identification, as well as a brown bag of food from a restaurant with no date. Staff interviewed confirmed the items should have been labeled with the resident's name and an expiration date, and that expired items should have been removed. Facility policies reviewed stated that resident food must be labeled with the resident's name, item, and use-by date, and food brought in by family or visitors must be labeled with content and date and consumed within 3 days or discarded.
Infection Control Lapse With Resident Belongings on Bedside Table
Penalty
Summary
The facility failed to ensure appropriate infection control practices for Resident #16. During initial rounds, a surveyor observed a pair of sneaker-like black shoes on the resident’s bedside table, with the inner soles marked with the resident’s name, and an unopened 4 oz container of apple juice placed next to the shoes. While in the room, a GNA entered to provide care and stated she had received infection control training and was not responsible for the shoes being on the bedside table. A Charge Nurse later stated the shoes should have been placed in the closet, then removed the shoes from the bedside table and discarded the apple juice. Record review showed the resident had multiple diagnoses including dementia and was dependent on nursing staff for dressing, grooming, and personal hygiene.
Failure to Reoffer Pneumonia Vaccinations
Penalty
Summary
The facility failed to screen and offer flu and pneumonia vaccinations to residents, as identified through record reviews and staff interviews. During a medical record review, Resident #20 was found to have been admitted and offered the pneumonia vaccine, which was refused, but there was no documentation that the vaccine was offered again while the resident remained in the facility. A review of Resident #138’s record showed the pneumonia vaccine had been offered and refused in 2018, but there was no documentation of any additional offers while the resident was still residing in the facility. During an interview, the Infection Preventionist stated that vaccinations are reviewed when it is time for flu vaccinations and that pneumonia vaccines would be offered again if previously refused. He confirmed the EMR showed the last pneumonia vaccine offer for Resident #20 was in 2020 and for Resident #138 was in 2018, and he checked the paper charts because the documentation might have been there. After reviewing the charts, he reported that he did not find documentation of additional pneumonia vaccine offers for either resident. The DON also confirmed that residents who refuse the pneumonia vaccination should be offered the vaccine again in the future.
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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 Laurel
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Autumn Lake Healthcare At Patuxent River | 1.5 mi | ★★★★★ | 23 | 0 |
| Autumn Lake Healthcare At Oak Manor | 4.9 mi | ★★★★★ | 24 | 0 |
| Riderwood Village | 5.8 mi | ★★★★★ | 17 | 0 |
| Autumn Lake Healthcare At Silver Spring | 5.9 mi | ★★★★★ | 15 | 0 |
| Fairland Center | 6.3 mi | ★★★★★ | 4 | 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 July 2026) and official state health department websites.