Above average — CMS composite of the measures below.
A standard survey is most likely before around October 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 Parkville during CMS and state inspections, most recent first.
Laundry Room Infection Control Lapse: Surveyors observed resident clean linen being folded and packaged on the clean table with ice water, disinfectant wipes, odor spray, lotion, and wash cloths placed on the same surface. A laundry assistant stated those items should not have been there, and the EVS manager acknowledged the same when shown the table.
A resident with multiple comorbidities and cognitive impairment was admitted with several pressure ulcers, but weekly skin assessments were not consistently completed and documentation was missing or incomplete. Additionally, a physician-ordered wound treatment was not signed off as administered on several occasions, and treatment for a specific wound was delayed. The DON confirmed that required assessments and documentation were not performed as expected.
Unclean and Unhomelike Resident Room: A surveyor observed an overwhelming urine odor in a resident's room, an uncovered commode with urine at the bedside, and a rusty vent by the window. Staff interviews confirmed repeated urine contamination in the room, with an LPN emptying the commode, a housekeeper reporting urine on the floor and in cups, and the EVS manager noting the pungent smell persisted despite deep cleaning.
A resident with a history of hemiplegia and hemiparesis had a decline in function and required substantial/max assistance for all ADLs, with PT, OT, and speech eval orders in place. However, the care plan lacked documentation showing it was developed to address the resident’s impaired mobility and transfer needs.
A resident with expressive aphasia and a stroke history was observed to be non-verbal but able to communicate with head nods, hand gestures, and a padded call bell. Surveyors found no communication board or other assistive device at the bedside, even though the care plan still listed a communication board as an intervention. Staff and the ST confirmed the board was not being used, and the DON acknowledged the care plan had not been reviewed and revised to reflect the resident’s current communication methods.
Staff failed to follow ordered care for multiple residents. A resident receiving tube feeding was found with the pump off but still connected, and the syringe at the bedside was not changed as ordered every 24 hours. Another resident reported meds were often late, and MAR review showed several doses given hours outside the scheduled time. Staff also did not ensure follow-up on a contaminated urine specimen for a resident with dysuria because the recollection order was not entered into the EHR.
A resident receiving continuous O2 at 2 L/min via nasal cannula was observed with oxygen tubing that had no date, time, or staff initials on it when the surveyor checked the setup. An RN confirmed the tubing was not labeled as expected, and the resident’s record showed an active order for continuous oxygen for SOB and a later order for weekly tubing changes and dating.
Failure to Address Resident Pain in Care Plan: A resident with chronic pain reported severe back pain despite receiving scheduled pain meds and a pain patch. Record review showed orders for hydromorphone and PRN acetaminophen, but the care plan was not updated to reflect an active pain focus or person-centered pain interventions. The unit manager acknowledged the care plan did not specifically address the resident’s pain treatment plan, and the DON stated the care plan addressed pain even though it did not.
Failure to document vital signs before giving Lisinopril: A resident with an order to hold the medication for low systolic BP or low HR had the drug administered daily, but the MAR did not show that BP or HR were checked before each dose. The DON stated the MAR lacked a place to record the required vital signs, so they were not documented.
Facility staff did not promptly notify a resident's representative after a significant change in the resident's condition, including the initiation of oxygen therapy and new diagnostic orders. The representative only learned of the change during a visit, and documentation confirmed that notification was delayed until after the event.
A resident receiving Hospice services did not have a person-centered care plan that addressed their specific needs, preferences, or end-of-life wishes. The care plan included only general interventions and lacked details about the resident's coping strategies, support system, and preferred comfort measures. Staff confirmed that the plan did not reflect individualized information necessary for effective Hospice care.
A resident with type 1 diabetes did not receive multiple scheduled doses of prescribed insulin because the medication was not available in the facility. Staff documented the missed administrations, notified the NP and MD, and monitored the resident for symptoms of hyperglycemia. There was also a documentation inconsistency where a dose was marked as given despite records showing the medication was unavailable. Facility leadership was made aware of these issues during the survey.
Staff did not maintain complete and accurate medical records for a resident on Hospice, failing to document required notifications to the Hospice provider and the resident's representative after a decline in condition and at the time of death. Progress notes lacked clarity regarding family presence at death and did not include an assessment supporting the determination of death.
Laundry Room Infection Control Lapse
Penalty
Summary
The facility failed to maintain infection control practices in the laundry room during the recertification/complaint survey. On 7/24/25 at 9:30 AM, the surveyor observed resident clean linen in various stages of folding and packaging on the clean folding table, along with 2 cups of ice water in 12 oz plastic cups, 2 Super Sani Disinfectant wipes, an 8 oz bye-bye odor spray, an 8 oz Aloe soft lotion (Geri-Geri), and 1 packet of wash cloths on the same table. During an interview at 9:50 AM, a laundry assistant described the laundry process from collection of dirty laundry in PPE, washing, drying, and then folding and packaging clean linen on the clean side, and stated that the supplies observed on the clean table should not have been there. At 9:57 AM, the EVS manager was shown the items on the clean folding table and acknowledged that the cleaning supplies and ice water should not have been on the table.
Failure to Complete Skin Assessments and Follow Wound Care Orders
Penalty
Summary
The facility failed to accurately complete a resident's skin assessment sheet and did not follow a physician's order for wound treatment. Upon admission, the resident, who was cognitively impaired, immunocompromised, and had multiple comorbidities, was documented as having several pressure ulcers. However, subsequent weekly skin assessments were not consistently completed, with missing or incomplete documentation on several dates. Additionally, the care plan listed multiple areas of impaired skin integrity, but the skin assessment sheets did not reflect all wounds, and some wound areas were not documented at all during certain assessments. Review of the Treatment Administration Record (TAR) revealed that a prescribed antiseptic wound medication was not signed off as administered on multiple occasions, and treatment for a left buttock wound was not ordered until several days after admission. The DON confirmed that skin assessments should be completed weekly and that nurses are responsible for signing off treatments, but acknowledged that these processes were not followed. These deficiencies were identified through record reviews and staff interviews during the survey.
Unclean and Unhomelike Resident Room
Penalty
Summary
The facility failed to ensure that a resident's room was clean, comfortable, and homelike. During the initial tour, a surveyor entered the resident's room and observed an overwhelming strong odor of urine coming from the room, including the bathroom. At the bedside, there was an uncovered commode less than one quarter full of urine, and a vent by the bedroom window had a brown rusty color all over it. The resident was lying in bed watching TV, and the resident's clothing and bedding did not appear or feel wet. The resident's speech was impaired and difficult to understand when the surveyor attempted to speak with them. Staff interviews confirmed ongoing concerns in the room. An LPN emptied the bedside commode after being asked about the urine odor and said he was not sure where it was coming from. The maintenance director stated the vent had been cleaned and painted before but had become rusty again because the resident urinates on it, and he said it would probably need replacement. A housekeeper stated the resident urinates on the floor, urinates in a cup and throws it on the floor, and that there is pee on the floor every time she goes in the room. The EVS Manager said mattress covers had been ordered and the room deep cleaned, but the pungent urine smell still could not be eliminated. The DON and NHA acknowledged the pungent urine smell and the rusty vent, and said they had discussed doing more frequent cleaning and taking out the floor.
Incomplete Care Plan for Impaired Mobility
Penalty
Summary
The facility failed to develop and implement a person-centered comprehensive care plan for Resident #82 that addressed the resident’s impaired mobility. During interview, the resident stated that he/she had declined in function since admission and had previously been able to get to and from the wheelchair independently but now needed help with transfers. Record review showed a history of hemiplegia and hemiparesis, and a June 10, 2025 MDS assessment indicated the resident was dependent and required substantial/max assistance for all ADLs. The resident also had orders for PT, OT, and a speech evaluation. Review of the care plan showed no documentation supporting that the resident’s care plan was developed to address the mobility needs identified in the assessment and history.
Care Plan Not Updated for Resident Communication Needs
Penalty
Summary
The facility failed to review and revise the interdisciplinary care plan for Resident #126 to reflect current communication interventions. The resident had a history of expressive aphasia and stroke, was non-verbal, and could communicate by nodding or shaking the head, using facial grimaces, pointing, and a padded call bell. During observation, the resident was awake in bed, and surveyors did not observe any communication system at the bedside, such as a board, cards, note pad, or tablet. The resident’s care plan, initiated in 2023 and revised in 2024, still listed a communication board as an intervention, but staff could not locate a board in the room, closet, or drawers, and the speech therapist confirmed that no communication board or assistive device was being used. The DON acknowledged that speech therapy had determined the resident did not need the communication board and confirmed the care plan had not been reviewed and revised to match the resident’s current communication methods.
Delayed Medications, Missed Tube Feeding Care, and Unfollowed Lab Results
Penalty
Summary
Staff failed to provide enteral feeding care in accordance with the physician’s order for a resident who was awake, alert, and oriented and connected to a tube feeding pump. During observation, the tube feeding pump was turned off while still connected to the resident, the Glucerna 1.5 cal bottle was almost empty, the water flush bag was undated, and a piston syringe dated two days earlier was hanging at the bedside. The resident stated not knowing when the pump had been turned off. The unit manager and night shift supervisor confirmed the bottle was almost empty, the pump was off but still connected, and the syringe date did not match the daily change expectation. A review of the active physician order showed the enteral feed syringe was to be changed every 24 hours. However, the resident’s MAR and TAR documented syringe changes on consecutive days while the syringe observed at the bedside remained dated earlier than the current date of observation. The documentation did not match the observed condition of the syringe, and the feeding set remained connected to the resident despite the pump being off. Staff also failed to administer medications within the facility’s stated time frame for another resident who reported that medications were often given late and that renal medications were not consistently given with meals as ordered. Review of the MAR showed multiple medication passes given well outside the scheduled time, including evening doses administered several hours late. In addition, staff failed to ensure follow-up on a contaminated urine specimen for a resident with dysuria; a nurse practitioner note stated the urine should be recollected, but no corresponding order was entered in the EHR, and nursing staff did not have the recollection order available to proceed.
Oxygen Tubing Not Labeled
Penalty
Summary
Facility staff failed to label the oxygen tubing when oxygen therapy was initiated for Resident #57. On 7/15/2025 at 9:55 AM, the surveyor observed the resident in bed wearing a nasal cannula connected to an oxygen concentrator set at 2 LPM. The tubing had no date, time, or staff initials noted on it at the time of the observation. At 10:20 AM the same day, RN #18 verified that the resident’s oxygen tubing was not labeled with the date/time it was hung and stated the expectation was to date label the tubing when it was changed. The resident’s record later showed an active physician order for oxygen at 2 L/min via nasal cannula continuously for shortness of breath for hospice, and an additional order for oxygen equipment to change and date tubing every week was entered after the surveyor’s observation. The DON later acknowledged the surveyor’s finding.
Failure to Address Resident Pain in Care Plan
Penalty
Summary
The facility failed to develop and implement a person-centered comprehensive care plan for Resident #84, who had an active pain issue and a diagnosis of chronic pain. During the survey, the resident reported severe back pain, including 9/10 pain during the initial screening interview and 8/10 pain the following day while resting in bed, even after receiving pain medication that morning, including a pain patch. Staff, including an LPN and the unit manager, were notified of the resident’s ongoing pain. A record review showed orders for HYDROmorphone HCl 2 mg tablets, 0.5 tablet by mouth twice daily for pain, and acetaminophen 325 mg, 2 tablets every 6 hours as needed for pain. On review of the care plan, the facility had not updated it to adequately address pain management as a focus area. The unit manager stated that care plan updates were done by the unit manager and acknowledged that the resident’s care plan did not specifically address the resident’s treatment plan for pain, even though additional pain management interventions were provided by a third-party service. The DON stated the care plan addressed pain, but the surveyor noted that the care plan only reflected a focus area of potential for alteration in comfort related to acute illness and chronic morbidities and did not address the resident’s actual pain using person-centered interventions.
Failure to Document Vital Signs Before Administering Lisinopril
Penalty
Summary
The facility failed to adequately monitor a resident's blood pressure and heart rate before administering Lisinopril 40 mg daily for hypertension. Resident #51 had an order to hold the medication for systolic blood pressure less than 110 or heart rate less than 60, but the resident's vital signs were documented only twice in July, while the MAR showed the medication was administered daily at approximately 10:00 AM throughout the month. There was no documentation showing that blood pressure and/or heart rate were checked prior to administration as ordered. When notified, the DON stated that the MAR did not have a place to document the blood pressure and/or heart rate, so the results were not recorded.
Failure to Notify Resident Representative of Significant Change in Condition
Penalty
Summary
Facility staff failed to notify a resident's representative following a significant change in the resident's condition and a change in the treatment plan. The resident, who had multiple diagnoses including stage 4 kidney disease, diabetes, hypertension, atrial fibrillation, and cellulitis, experienced acute shortness of breath with an oxygen saturation of 68%. The nurse administered oxygen and a nebulizer treatment, and the physician was notified, who then ordered labs and a chest x-ray. However, documentation showed that the resident's representative was not informed of these changes until nearly two days later, despite the initiation of new treatments and diagnostic procedures. The delay in notification was confirmed through medical record review, which indicated that the representative was only contacted after the representative discovered the resident on oxygen during a visit. The nurse later apologized for not notifying either of the resident's representatives about the change in condition. There was no documentation to show that the representative was informed at the time of the significant health status change or when the treatment plan was altered.
Failure to Develop Individualized Hospice Care Plan
Penalty
Summary
The facility failed to develop a person-centered Hospice plan of care that addressed the individualized needs and preferences of a resident receiving Hospice services. Medical record review showed that although a Hospice Plan of Care was created, it contained only general interventions and did not specify the resident's unique care needs, coping strategies, wishes, or preferences for end-of-life care. The plan also lacked details about which family members or friends the resident wanted involved in their support system and did not document specific comfort measures or end-of-life choices for staff to implement. During an interview, the Director of Social Services, who serves as the facility's Hospice Liaison, and the Administrator confirmed that the care plan did not identify the resident's specific end-of-life wishes or preferences. The surveyor pointed out these omissions, and both staff members acknowledged that the plan failed to include individualized information necessary for providing person-centered Hospice care.
Failure to Provide Timely Insulin Administration Due to Medication Unavailability
Penalty
Summary
A deficiency occurred when the facility failed to ensure that prescribed insulin medications were available and administered in a timely manner to a resident with type 1 diabetes. Upon admission following an acute hospitalization, the resident had orders for both long-acting and fast-acting insulin, including Basaglar and Novolog, to be administered at specific times and per sliding scale. Documentation in the electronic Medication Administration Record (eMAR) showed that several scheduled doses were not administered, with staff using a code indicating the medication was not given and referencing nurses' notes for further explanation. Review of the eMAR and associated progress notes revealed that the insulin was not available in the facility at the required times, resulting in missed doses. Staff documented that they were awaiting delivery from the pharmacy and that the nurse practitioner and physician were notified of the unavailability. Blood sugar checks during this period showed elevated glucose levels, and staff continued to monitor the resident for symptoms of hyperglycemia. Despite these actions, the prescribed insulin was not administered as ordered due to the lack of medication on hand. Additionally, there was a discrepancy in the documentation, as one administration time was marked as given despite other records indicating the insulin was not available. The facility's leadership, including the Nursing Home Administrator and Director of Nursing, were informed of the missed administrations and the documentation inconsistency. No further comments were provided by the facility leadership at the time of the survey.
Incomplete Documentation and Notification for Hospice Resident
Penalty
Summary
Facility staff failed to maintain complete and accurately documented medical records for a resident receiving Hospice services. The resident's medical record showed an instance of low blood pressure with no documentation that the resident's representative or Hospice provider was notified, as required by the facility's contract. Additionally, when the resident expired, the progress note did not clearly indicate whether the family was present at the time of death or arrived afterward, nor did it include an assessment supporting the determination of death. There was also no documentation of when, if, or how the Hospice provider was notified of the resident's death. These documentation gaps were confirmed by the Administrator and Director of Nursing.
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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 Loch Raven | 0 mi | ★★★★★ | 34 | 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 | 2.6 mi | ★★★★★ | 1 | 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.