Above average — CMS composite of the measures below.
The next survey window likely opens 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 Perring Parkway during CMS and state inspections, most recent first.
Homelike Environment Not Maintained: Surveyors repeatedly noted malodorous odors in the lobby and resident areas, along with worn, stained carpeting on both floors, chipped elevator flooring, damaged reception desk covering, and stained ceiling tiles and vents with debris and gray matter. Facility leadership acknowledged the odor and environmental concerns, and the DES stated odors were usually linked to dirty incontinence products in trash cans in resident rooms.
Failure to Maintain Resident Dignity: A resident with an ADL self-care deficit related to recent illness and deconditioning was observed in the hallway wearing a stained t-shirt on consecutive days, with bare feet on the floor. During a dual observation, the resident was also seen exposed in bed from the waist down, and the room had a strong odor with stained wheelchair linens. The resident’s care plan included staff assistance with bathing, dressing, toileting, bed mobility, ambulation, meal set up, and daily hygiene/grooming.
Advance Directive documentation was missing or misclassified for several residents. Staff treated the MOLST as the Advance Directive for some residents, while records for others showed assessments stating an Advance Directive was in place or that the resident wanted help completing one, but the chart did not contain a completed Advance Directive or documentation of assistance from SW or other staff.
Incomplete Baseline Care Plan for Newly Admitted Resident: A resident admitted with respiratory failure, emphysema, pulmonary hypertension, and major depressive disorder had a baseline care plan that did not include ordered psychotropic, diuretic, and opioid medications. The UM stated the baseline care plan should be completed within 48 hours and reviewed with the resident or representative, but the care plan lacked the medication-related monitoring and nursing considerations tied to diazepam, aripiprazole, duloxetine, trazodone, spironolactone, and oxycodone.
Failure to Hold Timely Quarterly Care Plan Meetings: The facility did not ensure timely quarterly care plan meetings were held so residents and/or resident representatives could participate in the care planning process. Survey review found gaps between MDS assessments and documented care plan meetings for two residents, and the NHA stated the facility had identified an issue with timely care plan meetings and documentation, but could not provide supporting records by exit conference.
A resident who used a wheelchair was not consistently offered the chance to attend group activities, despite an activities assessment showing interest in small groups, crafts, music, TV/movies, dogs, sports, and church. Staff mainly provided in-room coloring and limited documented activity participation, while the resident’s representative and caregiver said the resident would enjoy getting out of the room for music, games, and other group events.
A resident with lymphedema and dependence on staff for personal hygiene was observed with very dry, flaky skin on both lower legs. The condition was not documented in the chart, progress notes, or skin assessments, and the UM acknowledged the dry skin had not been addressed before surveyor intervention, despite the care plan calling for daily skin observation with ADL care.
A resident with cataracts and prior R eye surgery reported that the facility never scheduled the recommended L eye cataract surgery. Eye care notes documented bothersome cataracts, stable VA, and repeated recommendations for ophthalmology consult and cataract extraction, but the EMR did not show a scheduled appt after the most recent eye exam until a later physician order listed one.
Inconsistent incontinence care was identified for a resident who was totally dependent on staff for toileting and incontinent of bowel and bladder. The resident was observed in bed wearing a visibly wet incontinence product, and task records showed care documented only intermittently rather than every shift. An UM confirmed the resident’s dependence and noted documentation gaps, while surveyors also observed daily odors in resident hallways and nearby areas.
Respiratory tubing and humidification equipment were not managed as ordered for two residents. Surveyors observed missing date/time labels on oxygen tubing and humidification bottles, and one resident’s nebulizer machine, face mask, and tubing were laying on the floor. An LPN, UM, DON, and Administrator acknowledged the concerns, and the residents’ records showed orders to change and label the oxygen tubing components.
A medication room observation found a discontinued anticonvulsant and a discharged resident’s glucose monitoring supplies sitting on the counter instead of being placed in the pharmacy return bag. The UM confirmed the items were not stored as expected for medications awaiting final disposition.
A resident reported not having been seen by a dentist in a long time and had been requesting routine dental care for existing dentition and oral hygiene needs. The EMR showed the last dental consult was over a year earlier, with no documented routine dental appointments scheduled. RN and DON interviews confirmed the resident’s request for dental services, but no scheduled dental visit was provided by exit conference.
Failure to follow diet order and allergy information: A resident’s breakfast tray did not match the meal ticket or the resident’s documented preferences. The tray lacked bacon, oatmeal cereal, juice, coffee, and tea, while the ticket listed a CCD with bacon, oatmeal cereal, and beverages, and also incorrectly listed a beef allergy that was not found in the medical record. The resident stated drinks were often not served with meals and that coffee arrived too late or not at all.
A facility failed to follow the posted breakfast menu for two residents. One resident did not receive bacon, oatmeal cereal, or ordered drinks, and another resident did not receive French Toast Casserole listed on the meal ticket and posted menu. Staff confirmed the items were not served because the food truck did not come and the facility did not have the items in stock, and no documentation showed residents were informed of menu changes or offered choices.
A resident with severe cognitive impairment had incomplete documentation in the chart for advanced directives and incapacity determinations: the MOLST referenced a health care agent, but the record lacked an advanced directive, had only one physician incapacity certification, and did not contain physician documentation of review of the resident’s directives. Staff later confirmed the missing documentation was not in the chart. In a separate finding, an order for empagliflozin was documented for diabetes mellitus even though the resident had no diabetes diagnosis in the chart, and the DON and MD confirmed the medication was being used for a different indication.
A resident was observed using tube feeding equipment that was not dated, and the tubing and nutrition bottle were both confirmed to be undated by an assigned staff member. The staff member stated it was the nurse’s responsibility to ensure the tube feeding equipment was dated.
Homelike Environment Not Maintained
Penalty
Summary
The facility failed to ensure a homelike environment, as surveyors repeatedly observed malodorous odors and poor environmental conditions throughout both floors of the building during the recertification survey. On initial tour, a malodorous smell was present in the lobby area, and similar odors were later noted in the hallway near a resident room, near the first-floor elevator, and again in the lobby. The Administrator acknowledged the odor concern and stated it may have been due to nearby resident rooms adjacent to the lobby area. The Director of Environmental Services reported that odor control was part of his responsibilities and that odors were usually attributed to dirty incontinence care products in trash cans in resident rooms. Surveyors also observed widespread physical deterioration and soiling of the environment. Carpeting on both floors was worn, with areas where the pattern was no longer visible, along with dark gray areas, staining, and debris. Additional observations included dark staining in the doorways of multiple resident rooms, chipped flooring in the elevator, damage to the front reception desk with chipped and missing covering and a visible hole, and stained or dirty ceiling tiles and vents in resident hallways and above the floor 2 nursing station. Surveyors also noted black debris and thick gray matter within vents and debris along the edges of adjacent ceiling tiles. The facility’s Supervisor of Maintenance and DES acknowledged the concerns, and the Supervisor of Maintenance was observed cleaning the vents.
Failure to Maintain Resident Dignity
Penalty
Summary
The facility failed to ensure dignity was maintained for Resident #24. During the initial tour, the resident was observed sitting in a wheelchair in the hallway outside the room with bare feet on the floor and multiple orange stains on the t-shirt being worn. The next day, the resident was again observed in the hallway in the same stained t-shirt. During a dual observation with the Administrator, the resident was seen from the hallway lying in bed exposed with no clothing on from the waist down. When the concern was brought to the Administrator, a GNA was asked to assist with privacy, and the resident was covered with a blanket and the privacy curtain was pulled. At the time of interview, a strong odor was present in the room, and the linens on the resident’s wheelchair had brown stains. The Administrator observed the stained t-shirt and offered to have it changed, and the resident accepted. The medical record showed the resident had an ADL self-care deficit related to recent illness and subsequent deconditioning, with care planned for staff assistance with bathing, dressing, toileting, bed mobility, ambulation, meal set up, and daily hygiene, grooming, dressing, oral care, and eating as needed.
Advance Directive Documentation Missing or Misclassified
Penalty
Summary
The facility failed to ensure residents’ rights to formulate an Advance Directive and to maintain accurate documentation in the medical record for 4 of 6 residents reviewed for Advance Directives. For two residents, the electronic medical record and hard chart did not contain Advance Directive documentation, and staff identified the MOLST form as the Advance Directive. The administrator confirmed that the MOLST form was being considered an Advance Directive, although the surveyor informed staff that MOLST and Advance Directives are different documents under CMS regulations. For another resident, the record contained an Advance Directive admission assessment and a Social Service Assessment stating that an Advance Directive was in place and on file, but the electronic and paper records did not contain Advance Directive documents; the DON later provided only a MOLST form. For a fourth resident, Social Service documentation stated that the resident had been provided a copy of an Advance Directive for completion and wanted assistance with creating one, but the record did not show a completed Advance Directive or documentation that staff assisted with the process. The resident also needed help reading written material and was their own representative at the time of the assessments.
Incomplete Baseline Care Plan for Newly Admitted Resident
Penalty
Summary
The facility failed to ensure that Resident #99’s baseline care plan was thoroughly completed and included resident-specific initial goals based on admission orders needed to properly care for the resident immediately upon admission. The resident was admitted with diagnoses including acute and chronic respiratory failure with hypoxia, emphysema, absence of part of the lung, pulmonary hypertension, and major depressive disorder. During the admission period, the resident had physician orders for psychotropic medications including diazepam, aripiprazole, duloxetine, and trazodone, as well as spironolactone and oxycodone. A review of the baseline care plan showed that it did not include the resident’s psychotropic, diuretic, and opioid medications. The Unit Manager stated that the baseline care plan should be completed and implemented within 48 hours and that nursing staff were responsible for reviewing it with the resident and/or resident representative, providing a copy of the care plan and order summary, and answering questions. The surveyor and Unit Manager confirmed that the resident’s baseline care plan was not thoroughly completed upon admission to include the medications the resident was taking, despite the need for specific monitoring and nursing considerations associated with those medications.
Failure to Hold Timely Quarterly Care Plan Meetings
Penalty
Summary
The facility failed to ensure residents and/or resident representatives were offered the opportunity to participate in the care planning process by holding timely quarterly care plan meetings. During the annual survey, the surveyor reviewed care planning records for 4 residents and found this issue for 2 residents. The facility’s Social Worker and Nursing Home Administrator stated that initial care plan meetings are held within 7-14 days of admission and then quarterly, usually within the timeframe of the MDS assessments, with meetings also held for changes in condition or at the request of the resident or resident representative. For one resident, care plan meetings were documented on 2/1/2024, 6/20/2024, and 9/18/2025, while the electronic record showed multiple quarterly and annual MDS assessments between those dates, but no care plan meetings were found during several of those assessment timeframes. For the second resident, care plan meetings were documented on 6/9/2024, 11/22/2024, 2/26/2025, 4/24/2025, and 10/9/2025, while the record showed annual and quarterly MDS assessments on 3/19/2024, 5/2/2024, 8/3/2024, 11/3/2024, 12/20/2024, 3/20/2025, 6/20/2025, and 9/20/2025; the surveyor did not find care plan meetings held quarterly during the timeframe of several of those assessments. The NHA stated the facility completed a care plan meeting audit because it identified an issue with timely care plan meetings and documentation, but by exit conference the facility was unable to provide supporting documentation for timely quarterly care plan meetings for either resident.
Failure to Offer Resident Access to Group Activities
Penalty
Summary
The facility failed to ensure that a resident was offered the opportunity to participate in facility-sponsored group activities. Resident #54 used a wheelchair and needed staff assistance with transportation around the facility. The resident representative stated that the resident had been given coloring activities in the room but had not been observed being offered group activities or attending them, and said the resident would likely enjoy getting out of the room for group activities. Record review showed that Resident #54’s admission and annual activities assessment identified preferred activities including small groups, crafts, music, watching TV/movies, dogs, sports, and being invited to church. The activity care plan included a focus that the resident preferred not to attend group activities due to little motivational interest, with a goal to adjust positively to the facility by participating in independent or group activities of interest and an intervention to encourage participation in group activities of interest. Activity documentation reflected that staff reviewed the Daily Chronicle, provided coloring packets, and recorded limited participation such as prayer room visits, watching TV, and attendance at a Veterans Day ceremony, while the activity director stated staff should let residents know the daily activities and offer assistance to those who need it.
Unaddressed Dry Skin on Lower Extremities
Penalty
Summary
The facility failed to ensure Resident #24’s dry skin condition was identified and addressed. During observation, the resident was seen in a wheelchair and later in bed with very dry, visibly flaky skin on both lower extremities, and the resident had no socks or shoes on during the initial tour. The resident’s record showed a diagnosis of lymphedema and that the resident was dependent on staff for personal hygiene, but there was no documentation that the dry, flaky skin on the lower legs had been identified or addressed in the medical record, progress notes, or weekly skin assessments. The resident’s care plan included a problem related to a history of skin breakdown and risk for skin alteration due to limited mobility, intermittent incontinence, bilateral lower extremity edema, and lymphedema, with an intervention to observe skin condition with ADL care daily and report abnormalities. During interview, the UM confirmed the lower extremity skin was dry and stated lotion would be ordered, and also acknowledged the condition had not been addressed before surveyor intervention. After the surveyor raised the issue, an order for ammonium lactate cream was entered for dry skin.
Failure to Schedule Ophthalmology Follow-Up for Cataract Surgery
Penalty
Summary
The facility failed to ensure Resident #57 received proper treatment and scheduled follow-up appointments to maintain vision. During interview, the resident stated he had cataract surgery on the right eye and was supposed to have cataract surgery on the left eye, but the facility never scheduled the surgery. Record review showed an eye care note from 4/22/2024 documenting mixed cataracts in both eyes, bothersome vision, stable visual acuity, and a recommendation for cataract surgery with an ophthalmology consult and follow-up in 4-5 months. Further record review showed another eye care note from 6/27/2025 documenting a mixed cataract in the left eye and stating the resident had cataract surgery on the right eye months earlier and was supposed to return for the left eye but was never scheduled according to the patient. That note again recommended cataract surgery and an ophthalmology consult, with follow-up in 5-6 months and a request to schedule an outside ophthalmology appointment for further evaluation and extraction of bothersome cataracts. Review of the electronic medical record did not reveal an appointment scheduled after the 6/27/2025 eye exam, and the DON confirmed the concern and stated they would look into it. A physician order dated 12/1/2025 later showed an ophthalmology appointment scheduled for 12/5/2025 at 11:00 AM.
Inconsistent Incontinence Care Documentation and Wet Brief Observed
Penalty
Summary
Consistent incontinence care was not provided for Resident #4, who was documented in the medical record as totally dependent on staff for toileting needs and incontinent of bowel and bladder. During the initial tour on 11/24/25, the resident was observed in bed wearing a visibly wet, yellow incontinence care product. Review of the task documentation later showed incontinence care entries only on selected dates and times in late November and early December, with no evidence that care was documented consistently each shift. During interview, the Unit Manager confirmed that all GNAs are required to document care every shift and acknowledged that Resident #4 was dependent on staff for incontinence care and was incontinent. The Unit Manager reviewed the documentation with the surveyor and stated that it did not appear to have been documented, noting that the 3-11 shift was at 82% for documentation the prior day. The surveyor also noted that daily odors were present throughout resident hallways and adjacent areas during the recertification survey.
Respiratory tubing and humidification equipment were not labeled or properly stored
Penalty
Summary
Respiratory care was not provided in accordance with the facility’s documented orders for two residents. For Resident #98, the surveyor observed on 11/24/2025 that the nasal cannula oxygen tubing had no label showing the date or time it was placed or when it would expire, and the humidification bottle for oxygen also had no date or time label. At the same time, Resident #98’s nebulizer machine and face mask were observed laying directly on the floor next to the bed. An LPN observed the concerns and stated the tubing and mask should not be stored on the floor. The DON later stated the expectation was for respiratory tubing to be dated and timed with a label and confirmed that respiratory nebulizer equipment should not be stored on the floor’s surface. The record for Resident #98 showed an order beginning 11/03/2025 for oxygen tubing change weekly and to label each component with date and initials. For Resident #10, the surveyor observed on the initial tour that the oxygen tubing had no labeling present. The medical record showed an order beginning 7/23/25 for oxygen tubing change weekly and to label each component with date and initials. On 11/26/2025, the surveyor again observed Resident #10’s respiratory tubing with no label showing date or time, and the humidification bottle was sitting directly on the floor attached to the concentrator by extension tubing. A UM observed the concern and acknowledged it, stating they would take care of it. The Administrator was also informed and acknowledged the concern. The concern was again shared during the exit conference on 12/01/2025.
Improper Storage of Medications Awaiting Disposition
Penalty
Summary
The facility failed to ensure an appropriate storage method was used for medications awaiting final disposition in the Station 2 medication room. During observation, a bottle of levetiracetam oral solution for Resident #79 and a white paper bag containing a ONETOUCH Ultra 2 device, strips, and lancets for Resident #100 were found sitting on the medication room counter rather than being stored for return to pharmacy. Review of the records showed that Resident #79's levetiracetam oral solution had been discontinued on 11/20/2025, and Resident #100 had been discharged on 10/14/2025. During interview, the Unit Manager confirmed the items were on the counter and stated that discontinued medications and remaining medications for discharged residents were expected to be placed in a pharmacy-provided white plastic bag labeled return to pharmacy so they could be identified as ready for pickup by the pharmacy representative.
Failure to Assist Resident With Routine Dental Care
Penalty
Summary
The facility failed to assist Resident #57 in obtaining routine dental care. During an interview, the resident stated that they had not been examined by a dentist in a long time and had been requesting dental services for existing dentition and general oral hygiene. A review of the electronic medical record showed the last documented dental consult was dated 2/16/2024, and there was no documentation of any scheduled routine dental appointments. An interview with RN #21 confirmed that Resident #57 had requested to see the dentist. The DON stated that the facility provides dental services and that the dental company would see residents for emergency services without joining, while residents who did not qualify could be assisted with locating outside dental services. Despite the resident’s request and the lack of recent documented dental care, no scheduled dental appointment was provided to the surveyor by exit conference.
Failure to Follow Diet Order and Allergy Information
Penalty
Summary
The facility failed to provide a diet that met a resident’s special dietary needs and preferences. During breakfast observation, the resident stated that he or she was not allergic to beef, but the meal ticket listed a beef allergy and the tray did not match the ticketed meal. The resident reported that bacon and oatmeal cereal were supposed to be served, but the tray contained scrambled eggs, two sausage patties, and one piece of white toast, with no bacon, oatmeal cereal, juice, coffee, or tea. The resident also stated that drinks were not being provided with meals and that coffee was wanted with breakfast, but it was brought too late or not at all, leaving the resident finished eating or with cold food while waiting. The resident’s meal ticket for breakfast listed a carbohydrate controlled diet, four slices of bacon, 12 oz of oatmeal cereal, 12 oz of coffee or hot tea, 8 oz of orange juice, and allergies to dairy and beef. At the time of observation, the resident still had not received juice, coffee, or tea. Review of the medical record showed a diet order for a regular diet with regular texture and double portions, and the chart listed allergies to beans, cheese, and lactose, with no documentation of a beef allergy. Staff confirmed that the meal ticket stated the resident was to receive a carbohydrate controlled diet, bacon, oatmeal cereal, and drinks, and the DON confirmed that beef was not listed as an allergy in the medical record.
Menu Items Not Served as Posted
Penalty
Summary
The facility failed to follow the posted menu for residents’ meals. During observational rounds, Resident #8 stated that breakfast was supposed to include bacon and oatmeal cereal, but the tray did not contain bacon or oatmeal cereal. The resident also stated that drinks were not being served with meals and that coffee was wanted with breakfast, but it was often brought too late or not at all, leaving the resident either finished with the meal or eating cold food while waiting. Resident #8’s tray contained scrambled eggs, 2 sausage patties, and 1 piece of white toast, with no juice, coffee, tea, or oatmeal cereal, even though the meal ticket called for 4 slices of bacon, 12 oz of oatmeal cereal, 12 oz of coffee or hot tea, and 8 oz of orange juice. Resident #58 stated that French Toast Casserole was not received for breakfast, and the meal ticket for that resident listed French Toast Casserole - 2 squares. The posted menu in the hallway listed French Toast Casserole, bacon, hot or cold cereal, and a choice of milk, juice, coffee, or tea. Staff confirmed that residents did not receive the breakfast items listed on the menu and stated that bacon and French Toast Casserole were not in stock because the food truck did not come and the supply company was out of stock. No documentation or verification was provided showing that residents were informed of menu changes or offered resident choices when items were unavailable.
Incomplete advance directive documentation and inaccurate medication indication
Penalty
Summary
The facility failed to ensure Resident #10’s medical record contained complete and accurate documentation related to advanced directives and incapacity determinations. The resident was admitted with severe cognitive impairment and had a MOLST form in the record that identified a health care agent, but the record did not contain an advanced directive, and only one certification of incapacity signed by one physician was present. The resident’s face sheet listed a healthcare surrogate, and the hospital discharge summary documented that a surrogate decision maker existed before admission, but no physician documentation was found showing review of the resident’s advanced directives in the facility record. During surveyor review, facility staff confirmed that the second certification of incapacity and the advanced directive should have been in the hard chart, but they could not locate them. The DSS stated the MOLST being followed had last been completed by the hospital, and the DON and physician acknowledged that the medical director was being contacted because the second certification could not be found. The surveyor later obtained two certifications of incapacity dated the same day as surveyor intervention, and a MOLST form was then observed signed by the physician indicating the basis for the orders was the patient’s surrogate. The facility also failed to ensure the accuracy of a medication order for Resident #24. The resident had an order for empagliflozin 10 mg daily documented for diabetes mellitus, but the resident’s diagnosis list, care plan, and physician progress notes did not show a diagnosis of diabetes. The DON stated the resident did not appear to be diabetic, and the medical director confirmed the medication was not being given for diabetes mellitus. After surveyor intervention, the order was revised to list congestive heart failure as the indication.
Undated Tube Feeding Equipment
Penalty
Summary
The facility failed to ensure tube feeding equipment was properly dated for Resident #9, who was observed using a tube feeding that was not dated. During the observation on 11/24/2025 at 10:27 AM, the tubing and nutrition bottle were both found to be undated. Staff #10, who was assigned to the resident, confirmed the equipment was undated and stated it was the nurse’s responsibility to ensure the tube feeding equipment was dated. The Director of Nursing was made aware of the findings on 11/25/2025 at 10:48 AM.
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Illustrative
What surveyors actually found near you
We read the 1,538 citations issued within 25 miles in the last 12 months — including the 5 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
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 | 1.7 mi | ★★★★★ | 18 | 0 |
| Autumn Lake Healthcare At Loch Raven | 1.7 mi | ★★★★★ | 34 | 0 |
| Good Samaritan Nursing Home Operator, Llc | 1.7 mi | ★★★★★ | 4 | 0 |
| Autumn Lake Healthcare At Overlea | 2.2 mi | ★★★★★ | 5 | 0 |
| Future Care Cold Spring | 2.3 mi | ★★★★★ | 29 | 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.