Below average — CMS composite of the measures below.
A standard survey is most likely before around September 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 Pikesville during CMS and state inspections, most recent first.
Surveyors identified failures in infection prevention and control, including unclear Enhanced Barrier Precautions (EBP) signage in double-occupancy rooms, lack of accessible infection control supplies, and staff confusion about which residents required EBP. Additionally, clean laundry was stored in a room with stained, damp walls and a ceiling hole with debris, raising concerns about contamination.
Facility staff did not administer several medications to a resident within the required 1-hour time frame, resulting in significant medication errors. Multiple medications, including antihypertensives, supplements, and pain relievers, were given at times that did not align with physician orders. The DON was unable to provide an explanation when interviewed about these findings.
Two residents who were highly functioning and in stable health reported that their requests for discharge and independent living were not properly facilitated by staff. Both experienced delays and lack of follow-up due to staff turnover and gaps in social work coverage, resulting in unaddressed discharge planning and incomplete documentation.
The facility did not provide two residents with the required Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage, and one resident did not receive the Notice of Medicare Non-coverage. These forms are necessary to inform beneficiaries about Medicare coverage status, potential financial liability, and appeal rights. The deficiency was confirmed through record review and administrator interview.
Surveyors identified multiple areas within the facility, including a housekeeping closet, utility room, medication room, and a resident bathroom, that were not maintained in a clean or functional state. Issues included standing water with foul odors, clogged drains, unclean toilets, sinks with visible buildup, lack of hand hygiene supplies, and damaged bathroom fixtures. Facility leadership confirmed these observations during the survey.
A staff member failed to immediately report a witnessed incident of alleged verbal and physical abuse by a nurse toward a resident. Although the abuse allegation was later unsubstantiated, the delay in reporting violated the facility's protocol for timely reporting of suspected abuse.
Two residents did not have their comprehensive care plans developed within the required timeframe or with full IDT participation. In both cases, only select staff such as the Activities Director, LPN, Dietician, and Social Work Director were involved, with no documented input from the attending physician, RN, or nurse aide. Additionally, one resident's care plan lacked timely completion and did not include participation from the resident or their representative.
A resident received multiple medications outside the prescribed 1-hour administration window, including garlic orals, hydralazine HCL, zinc, magnesium oxide, naproxen, and forastor. These medications were given several hours late, and the DON was unable to provide an explanation during the survey. This resulted in a failure to meet professional standards for medication administration.
Surveyors found that two residents did not have up-to-date social work documentation or follow-up regarding their requests for discharge, due to a gap in social work staffing and incomplete medical records. The deficiency was confirmed through interviews and review of available documentation.
A resident was observed lying in bed with legs dangling over a significant gap between the mattress and the bed frame footboard. Measurement by the Maintenance Director confirmed an 8 ½ inch gap due to the mattress being the wrong size for the bed frame.
A resident reported and surveyors observed numerous black flying insects present in one room and bathroom, with approximately 14 pests seen flying and on the walls. The deficiency was confirmed through interviews and direct observation, indicating a lapse in the facility's pest control program.
Failure to Maintain Infection Prevention and Control Standards
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple deficiencies observed during survey rounds and interviews. Surveyors found that Enhanced Barrier Precautions (EBP) signage was inconsistently applied and did not clearly identify which resident in double-occupancy rooms required precautions. In several cases, EBP signage was present without corresponding infection control supplies available for staff use, and staff were unable to identify which resident the precautions applied to. Medical record reviews revealed discrepancies, including signage for residents not on EBP and lack of clear identification for those who were. Staff interviews confirmed confusion regarding the identification system, with inconsistencies noted in the use of green dots to mark residents requiring EBP. Additionally, the facility failed to maintain proper infection prevention standards in the laundry area. Observations revealed that clean laundry was stored against stained, damp, and peeling cement walls, and directly beneath a large hole in the ceiling with protruding debris. These conditions were present in the room where clean laundry was processed, posing a risk for contamination. The facility administrator was made aware of these environmental concerns during the survey.
Failure to Administer Medications Within Prescribed Time Frames
Penalty
Summary
Facility staff failed to administer medications in accordance with professional standards, resulting in significant medication errors for one resident. The errors were identified through observation, record review, and interview. Specifically, the resident's medications were not given as prescribed by the physician, violating the five rights of medication administration: right person, right medication, right route, right dosage, and right time. On a specific date, multiple medications for the resident were administered outside the required 1-hour time frame. These included garlic orals, hydralazine HCL, zinc, magnesium oxide, naproxen, and forastor capsules, all of which were given at times significantly later or earlier than scheduled. The findings were discussed with the Director of Nursing, who did not provide a response at the time of the interview.
Failure to Facilitate Resident Discharge Choices Due to Staff Turnover and Lack of Follow-Up
Penalty
Summary
The facility failed to ensure that residents' choices regarding discharge were properly facilitated, as evidenced by the experiences of two residents. One resident expressed a desire for a private living arrangement where family and friends could visit without restrictions and where they could have more autonomy, including going outside at will. This resident reported that the discharge process had been initiated three times but was never completed due to staff turnover, leaving them and others waiting for assistance. The Director of Social Work (DOSW), who had only been in her position for thirty days, was not aware of the resident's specific wishes and stated she would follow up. Another resident also reported wanting to leave the facility and live independently, stating that they had not received assistance with the discharge process and had not been followed up with for months. The Nursing Home Administrator confirmed that the previous social worker had left several months prior and that a consultant was only providing services once a month. The current DOSW was unable to provide follow-up documentation for either resident during the period after the previous social worker's departure, indicating a lack of continuity and follow-through in supporting residents' discharge choices.
Failure to Provide Required Medicare Coverage and Liability Notices
Penalty
Summary
The facility failed to provide required Medicare notifications to residents regarding coverage and potential financial liability for services not covered. Specifically, record reviews and staff interviews revealed that two residents were not given the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (CMS-10055), which is intended to inform beneficiaries when Medicare may no longer cover their skilled services and to clarify their payment responsibilities if they choose to continue receiving those services. The facility's own completion of the SNF Beneficiary Protection Notification Review form (CMS-20052) confirmed that these notifications were not issued as required. Additionally, one of these residents was not provided with the Notice of Medicare Non-coverage (CMS-10123), which is necessary to inform beneficiaries of their right to appeal and request an expedited review when Medicare coverage is ending. During interviews, the Nursing Home Administrator acknowledged that the required forms were not provided to the affected residents, as indicated on the facility's internal review documentation.
Failure to Maintain Clean and Functional Environment in Resident and Staff Areas
Penalty
Summary
Surveyors observed multiple deficiencies related to the facility's failure to maintain a clean, functional, and homelike environment. During observation rounds, a housekeeping closet on the 1 West Wing was found to have approximately two inches of standing, dark green and black water in the floor drain, emitting a musty, earthy, and decaying wood odor. The Environmental Service Director confirmed the drain was clogged and required cleaning. In the same wing, a utility room contained a toilet bowl filled with dark green and brown water, also producing a musty, earthy odor, which the Maintenance Director acknowledged should not occur and indicated the toilet should be clean. Further observations revealed that the medication room on the 1 West Wing had a sink with a dark green and reddish-brown flaky substance around and inside the drain, and lacked paper towels or similar items for staff handwashing. The Maintenance Director confirmed the sink's condition and the absence of hand hygiene supplies. In a resident room, the bathroom contained a toilet with a cracked water tank, a green, white, and black hard substance on the toilet handle, and a bedside commode over the toilet base with a reddish-brown flaky substance on its front and legs. The Nursing Home Administrator was made aware of these findings during the survey.
Failure to Immediately Report Alleged Abuse
Penalty
Summary
Facility staff failed to immediately report an allegation of abuse involving Resident #19. According to the facility's investigation and a statement from a Geriatric Nursing Assistant (GNA), the GNA witnessed a nurse verbally and physically abuse the resident but did not report the incident immediately as required. The facility's administrative review confirmed that staff are trained to report abuse allegations to management without delay, and the expectation was reiterated by the Administrator during interviews. The investigation ultimately found the abuse allegation to be unsubstantiated, but the delay in reporting by the GNA constituted a failure to follow established protocols for timely reporting of suspected abuse.
Failure to Develop Comprehensive Care Plans with Full Interdisciplinary Team Participation
Penalty
Summary
The facility failed to ensure that comprehensive care plans were developed within 7 days of the comprehensive assessment and that these care plans were prepared, reviewed, and revised by the full interdisciplinary team (IDT) as required. For one resident, the care plan conference summary indicated that only the Activities Director, Unit Manager (LPN), Dietician, and Social Work Director participated in updating the care plan, with no documentation of participation or input from the attending physician, a registered nurse, or a nurse aide responsible for the resident. Additionally, there was no evidence that these missing team members communicated their updates to the care plan. For another resident, the comprehensive care plan was not completed within the required 7-day timeframe following the comprehensive assessment. The care plan conference summary lacked documentation of participation from the resident or their representative, and the only signatures present were from the Director of Social Work, Director of Activities, and Dietician. Attempts to contact the resident's family for participation were unsuccessful, and there was no documentation of involvement from the attending physician, registered nurse, or nurse aide. Staff interviews confirmed the absence of documentation supporting full IDT participation in the care plan development.
Failure to Administer Medications According to Professional Standards
Penalty
Summary
Facility staff failed to administer medications in accordance with professional standards, resulting in significant medication errors for one resident. The errors were identified through observation, record review, and interview. Specifically, the resident's medications were not given as prescribed by the physician, with multiple medications administered outside the required 1-hour time frame. The medications affected included garlic orals, hydralazine HCL, zinc, magnesium oxide, naproxen, and forastor, all of which were given at times significantly later than scheduled. The medication administration audit revealed that these deviations from the prescribed schedule occurred on a specific date, with some medications being administered several hours late. During an interview, the Director of Nursing was unable to provide a response regarding these findings. The report documents that the facility did not ensure residents were free from significant medication errors, as required by professional standards and the five rights of medication administration.
Failure to Maintain Accurate Medical Records and Follow-Up for Resident Discharge Requests
Penalty
Summary
Surveyors identified that the facility failed to maintain accurate and up-to-date medical records for two residents. Both residents expressed a desire to leave the facility and reported that their requests for assistance with discharge had not been addressed for an extended period. Interviews revealed that the discharge process for one resident had been initiated multiple times but was not completed due to staff turnover. The other resident also reported a lack of follow-up regarding their request to leave. Documentation provided by the current Director of Social Work showed that the last social work notes for these residents were from several months prior, with no follow-up notes available during the period after the previous social worker left. The facility administrator confirmed that there was a gap in social work coverage following the departure of the previous social worker, which resulted in a lack of documentation and follow-up for the affected residents. The current Director of Social Work had only recently started and was unable to provide documentation of ongoing social work interventions for the residents during the interim period. This lapse in maintaining accurate and complete medical records was discussed with the administration team during the exit conference.
Incompatible Bed Mattress and Frame Resulting in Unsafe Gap
Penalty
Summary
The facility failed to ensure compatibility between a resident's bed mattress and bed frame. During observation rounds, a resident was found lying in bed with their legs dangling over a gap between the end of the mattress and the bed frame footboard. Further inspection and measurement by the Maintenance Director revealed an 8 ½ inch gap, and it was confirmed that the mattress was the wrong size and did not fit the bed frame. This deficiency was identified in one out of 25 resident beds reviewed during the survey. No information regarding the resident's medical history or condition at the time of the deficiency was provided in the report.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of pests in a resident's room and bathroom. During an interview, a resident reported that numerous black flying bugs were present in the room and would fly around their head while eating. Subsequent observation confirmed the presence of approximately 14 black, winged pests flying and resting on the walls in the resident's room and bathroom. These findings were based on direct observations and interviews conducted during the survey. The deficiency was specifically noted in one resident's bathroom out of 25 observed during the survey, with both the resident and staff acknowledging the presence of pests in the affected area.
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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 Pikesville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| King David Nursing And Rehabilitation Center | 0.8 mi | ★★★★★ | 22 | 0 |
| Courtland, Llc | 1.5 mi | ★★★★★ | 6 | 0 |
| Resorts Of Augsburg | 1.7 mi | ★★★★★ | 40 | 0 |
| Lochearn Nursing Home, Llc | 2.3 mi | ★★★★★ | 17 | 0 |
| North Oaks Communities | 2.5 mi | ★★★★★ | 13 | 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.