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 Summit Park during CMS and state inspections, most recent first.
Pest control program failure with mouse activity, droppings, and gnat/fly sightings throughout the facility. A resident reported recent mouse sightings in their room, surveyors observed mouse droppings and insects across all 4 units, and pest logs documented mouse activity in one room and droppings in another, with fly treatment noted in the D wing.
A facility failed to treat residents with dignity during lunch service when 1 staff member handed out trays to 13 residents one table at a time. At each of 5 tables, one resident was served before the other resident(s), and some residents waited about 4 to 7 minutes after their tablemate had already started eating. The staff member stated that residents needing less help were served first and those needing more help were served afterward, regardless of seating.
Failure to provide activities to meet resident needs was identified for two residents. One resident wanted more activity participation and needed guidance and transport, but records showed very limited activity involvement and only two one-to-one sessions in part of the month despite no refusals. Another resident’s representative reported the resident stayed in bed and did not participate in activities, and records showed no activities in one month and only limited activity days in the next, with staff confirming no one-to-one activities were provided despite the facility’s expectation for dependent residents.
Failure to Complete Annual GNA Performance Evaluations: The facility did not complete yearly performance evaluations for 3 of 3 GNAs reviewed. Personnel file review showed no current annual evaluations for the staff members, and the HR Director confirmed the DON was responsible for the evaluations. The DON also confirmed that the evaluations had not yet been completed.
Two residents experienced deficiencies in their living environment, including a malfunctioning bathroom sink with no cold water and persistent dust and black dots on curtains and bathroom door frames. These issues were confirmed by surveyors through interviews and direct observation.
A resident was not provided with a summary of their baseline care plan, including a list of medications, within the required timeframe after admission. Review of records and staff interviews confirmed that there was no documentation or evidence that the summary was given or reviewed with the resident.
Two residents did not have individualized care plans addressing their specific clinical needs: one receiving regular oxycodone administration and another with an indwelling foley catheter. Despite documentation of these conditions in medical records, the facility failed to include appropriate focus areas, goals, or interventions in the care plans, as confirmed by staff interviews.
The facility failed to follow physician orders and care plans for one resident who was supposed to wear hipster padded briefs and have heels floated, but was observed without the briefs and with heels not floated, and staff admitted documentation was inaccurate. The facility also failed to provide or document toileting hygiene for two incontinent residents who were dependent on staff, with records showing missing care documentation and one resident repeatedly marked not available even though records showed the resident remained in the facility.
A resident without an identification wrist band had their blood drawn by mistake after a lab tech entered the room and performed the procedure on the wrong individual. The error was discovered when a visitor noticed bandaging and, after inquiry, learned of the incident. Facility staff were initially unaware until a grievance was filed, and an investigation confirmed the absence of the required ID band at the time of the error.
Two residents experienced significant medication errors when an LPN administered an incorrect dose of Clonazepam to one resident and gave Lispro insulin to another due to misidentification. Both errors were discovered through documentation review and staff interviews, with the affected residents monitored for adverse reactions.
A resident with a change in mental status was not provided a physician-ordered urine analysis (UA), and there was no documentation of either the test result or a refusal. The DON stated the UA was not obtained due to resident refusal but could not provide supporting documentation.
Missing PASARR Screening on Admission: A resident with schizoaffective disorder, bipolar disorder, and generalized anxiety disorder was admitted without a completed Level 1 PASARR in the record. Review showed the hospital had not fully completed the PASSAR Level 1, and Telligen would not review the submitted screening because psychiatric notes were missing. The social worker stated it was her responsibility to verify PASARR completion before admission and confirmed the resident did not have an approved Level 1 PASARR.
Failure to provide scheduled showers and personal hygiene for dependent residents. Two residents were assessed as dependent for showers and personal hygiene, yet shower logs showed they received far fewer showers than scheduled. One resident’s records showed only a few showers over the month, and the DON confirmed the documentation. For the other resident, a representative reported poor hygiene, the resident was observed in the same clothes on consecutive days, and staff confirmed the resident was not receiving showers as required.
Failure to turn and reposition a resident with a Stage 4 sacral wound was identified. Weekly wound assessments showed the wound worsened, and GNA documentation showed multiple shifts where the resident was not turned or repositioned every 2 hours or where no turn-and-reposition documentation was entered. The DON acknowledged the concern with the resident’s turning and repositioning care.
A resident with an oxygen order for 2 L/min via NC PRN at bedtime was found with oxygen set at 10 L/min, while the resident reported using 7 L/min at night to sleep comfortably. Staff confirmed the order in the chart, and the ADON stated nursing should monitor the oxygen rate when in use. The MAR/TAR review also showed nursing had not been documenting that the resident was receiving oxygen therapy as needed.
Failure to follow ordered fall and positioning interventions. A resident with a recent fall and right clavicle fracture was ordered to wear a hipster padded brief while awake, float heels in bed, and wear a sling on the R arm. Survey observations found the resident wearing regular briefs, without the sling, and with heels not floated while sleeping. An LPN confirmed the interventions were not in place and stated documentation inaccurately showed the resident had been wearing the sling and padded brief.
Failure to use proper hand hygiene during wound care was observed for a resident with multiple pressure ulcers, including a facility-acquired stage 4 sacral ulcer and an unstageable R foot ulcer. During a dressing change, an LPN performed hand hygiene at the start, removed a contaminated sacral dressing, then continued wound cleansing and dressing application without performing hand hygiene between the dirty and clean steps. The LPN later stated that hand hygiene is expected after removal of a dirty dressing and that this step was forgotten.
Pest Control Program Failure
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by mouse activity and widespread insect sightings across all 4 units. During complaint review, it was alleged that Resident #52’s room had a common problem with mice. On observation of Resident #52’s room, no mice were seen, but mouse droppings had been observed by another surveyor during the initial pool process, along with gnat and fly sightings made by surveyors throughout the facility. Resident #52 stated the last mouse sighting was about 2 weeks earlier. Review of pest control logs showed a mouse was spotted in room D10 and treated by the pest management company, and later mouse droppings were found in Resident #52’s room (D18) with glue boards placed afterward. The maintenance director stated the pest control company was doing better sprays of rooms for gnats and that furniture was moved to ensure old food was picked up and cleaned appropriately. A pest service report also documented treatment for reported fly activity in the D wing.
Dining Trays Served to Tablemates at Different Times
Penalty
Summary
The facility failed to treat residents with dignity while dining. During a lunch observation in the 2nd floor dining room, 13 residents were receiving meals from a tray cart with assistance from 1 staff member. The staff member handed out 1 tray to a table at a time, with each table having at least 2 residents and 5 tables in the dining room. Five residents received trays on the first pass, and then another resident from each table received a tray on the second pass, leaving those residents waiting approximately 4 to 7 minutes after the first tray at their table was served. During that wait, the residents who received trays first had already begun eating. In interview, the staff member stated that residents who need less help are served first and those who need help are served afterward regardless of where they are sitting.
Failure to Provide Activities to Meet Resident Needs
Penalty
Summary
The facility failed to provide activities to meet the needs and preferences of residents, as shown for two residents reviewed during the recertification survey. Resident #88 was observed in their room with the TV off, and the record showed the resident had activities on only 2 days from 8/1/25 through 8/13/25 and on 4 days during July 2025. The care plan stated the resident wanted to participate in more activity programs but needed guidance and transport, and a note indicated staff would conduct one-to-one visits if the resident did not wish to join group activities. The activities log reviewed with staff confirmed no refusals and showed the resident received one-to-one activity only twice from 8/1/25 through 8/13/25, despite staff stating the expectation for dependent residents was one-to-one activities 3 times per week. Resident #103’s representative stated the resident always stayed in bed and did not participate in any activities. Review of the electronic record did not show participation in activities, and the facility’s July and August 2025 activities log showed no activities provided during July and only 3 days of activities from 8/1/25 through 8/14/25. Staff confirmed the resident did not receive any one-to-one activities in July, even though the facility’s expectation was to provide dependent residents with one-to-one activities 3 times a week. The DON was made aware of the concerns regarding activities provision for dependent residents.
Failure to Complete Annual GNA Performance Evaluations
Penalty
Summary
The facility failed to complete yearly performance evaluations at least every 12 months for 3 of 3 Geriatric Nursing Assistants reviewed. During review of personnel files for Staff #13, Staff #14, and Staff #15, surveyors found no performance evaluations completed within the last 12 months. Facility records showed Staff #13 was hired on 12/14/28, Staff #14 on 6/20/2010, and Staff #15 on 5/21/24, but the files did not contain current annual evaluations. The Human Resource Director stated that the DON was responsible for completing annual nurse assistant performance evaluations and confirmed that Staff #15 had no evaluation on file, Staff #13's last evaluation was on 10/25/2023, and Staff #14's last evaluation was on 8/14/2023. The DON later confirmed that he had not yet completed performance evaluations for Staff #13, Staff #14, and Staff #15.
Failure to Maintain a Homelike and Clean Environment in Resident Rooms
Penalty
Summary
Surveyors identified deficiencies in the facility's maintenance of a homelike environment in two resident rooms. In one instance, a resident reported that their bathroom sink did not have working hot water, and observation confirmed that only the hot-water faucet handle was functioning, with no water coming from the cold-water faucet. The issue was brought to the attention of the unit manager, and the Director of Nursing was later questioned about the status of the repair, at which point they were not yet aware of the problem. In another room, a resident reported that the curtains were consistently dusty and not being cleaned properly, and also pointed out black dots on the bathroom door frame. The surveyor confirmed the presence of large pieces of dust and white particles on the curtain, as well as black dots extending from the top of the door frame to the wall above. These environmental concerns were verified through observation and photographs, and the Maintenance Director was informed of the findings.
Failure to Provide Baseline Care Plan Summary to Resident
Penalty
Summary
The facility failed to ensure that a resident was provided with a summary of their baseline care plan, including a list of medications, within 48 hours of admission. Record review showed that although a baseline care plan was completed, there was no evidence, such as signatures or documentation, indicating that the resident had reviewed or received the summary. Interviews with the social worker confirmed that the facility's process was to document this in a progress note, but no such note was found in the resident's file. Both the Director of Nursing and the administrator were made aware of the lack of documentation and provision of the baseline care plan summary.
Failure to Develop Individualized Care Plans for Residents with Opioid Use and Indwelling Foley Catheter
Penalty
Summary
The facility failed to develop individualized care plans for two residents with specific clinical needs. For one resident who was prescribed oxycodone 10 mg orally every 6 hours as needed for pain, there was no care plan addressing the use of this opioid medication. Record review showed that the resident received oxycodone twice daily for 24 days in August, yet no care plan or monitoring interventions related to opioid administration were documented. The DON confirmed that a care plan should have been in place for this medication order. In another case, a resident admitted with an indwelling foley catheter did not have a care plan that included focus areas, goals, or interventions for catheter management. Although the baseline care plan and admission MDS documented the presence of the catheter, the comprehensive care plan lacked any mention of it. This omission was confirmed by both the director of social work and the DON during interviews.
Failure to Follow Orders and Provide Toileting Hygiene
Penalty
Summary
The facility failed to provide treatment and care according to physician orders and resident care plans for Resident #88. The resident had orders to wear hipster padded briefs every shift while awake as a fall intervention and to have heels floated while in bed. The record also showed the resident was care planned for these interventions. However, the resident was observed without the hipster padded briefs on 8/13/25, and on 8/14/25 the resident was observed sleeping in bed with heels not floated. Staff #5 confirmed during observation that the resident was not wearing the padded brief and the heels were not floated, and later stated that documentation had been entered inaccurately. The facility also failed to provide toileting hygiene for Resident #137, who was coded as always incontinent of bowel and bladder and dependent on staff for toileting hygiene. A complaint alleged that the resident did not get a diaper change on 12/1/23 and that staff did not change the diaper during various shifts. Review of the record showed the resident needed assistance with toileting and was dependent on staff, but the facility could not produce documentation showing toileting hygiene for the November 30 night shift, and there was no documentation for several other shifts in late November and early December. The DON stated that toileting hygiene documentation would be expected if care was provided. The facility also failed to document and provide toileting hygiene for Resident #126, who was dependent on staff for toileting hygiene and always incontinent of bowel and bladder. A complaint alleged the resident did not get a diaper changed in a timely manner. When records were reviewed for January and February 2025, the facility provided documentation only for January, and several dates showed the resident was marked not available for care. Other dates had no documentation at all, and the resident’s MAR and progress notes showed the resident never left the facility. The DON stated it would be very unlikely for a resident to be away the entire shift and later acknowledged the resident was in the facility on the dates marked not available, with no additional information showing toileting hygiene care was provided.
Failure to Ensure Resident Identification Led to Blood Draw Error
Penalty
Summary
A deficiency occurred when a resident did not have an identification wrist band, which resulted in the wrong individual having their blood drawn. The incident was discovered after a complainant noticed gauze and tape on the resident's hand during a visit and learned from the roommate that a lab technician had mistakenly drawn the resident's blood. Facility staff were initially unaware of the incident until a grievance was filed. A review of facility grievances and subsequent investigation confirmed that the resident did not have an armband at the time of the error, directly leading to the mistaken blood draw.
Significant Medication Errors Due to Incorrect Dosing and Resident Misidentification
Penalty
Summary
The facility failed to prevent significant medication errors for two residents. In one instance, a resident received 2 mg of Clonazepam instead of the ordered 1 mg dose. The error was discovered during a medication count at shift change, and documentation showed that the medication order had been revised to specify only one tablet should be given. The resident's progress notes indicated a change of condition following the administration of the incorrect dose, and the error was confirmed through review of the medication administration record and staff statements. In another case, a resident was administered 4 units of Lispro insulin due to the nurse misidentifying the resident by picture and name. The error was documented in the resident's progress notes, which indicated that the resident remained stable with no signs of hypoglycemia or hyperglycemia following the incident. The incident report confirmed that the LPN did not properly identify the correct resident before administering the medication.
Failure to Obtain and Document Ordered Laboratory Test
Penalty
Summary
A deficiency occurred when the facility failed to obtain a laboratory test as ordered by the physician for one resident. The resident experienced a change in mental status with paranoid delusions, prompting the physician to order a urine analysis (UA) to rule out a possible urinary tract infection. Upon review, there were no documented results for the ordered UA, nor was there any documentation indicating that the resident refused the test. During an interview, the Director of Nursing stated that the UA was not obtained due to resident refusal but was unable to provide any documentation to support this claim. The absence of both the laboratory result and documentation of refusal was confirmed during the survey.
Missing PASARR Screening on Admission
Penalty
Summary
Failure to ensure a resident's PASARR form was completed on admission was identified for one resident reviewed for PASARR screening. The resident was admitted to the facility on 1/22/25 and had diagnoses of schizoaffective disorder, bipolar disorder, and generalized anxiety disorder. Review of the medical record did not reveal Level 1 PASARR screening documentation, and the facility was asked to provide evidence of the screening documentation. Further review showed that the resident's PASSAR Level 1 had not been fully completed by the hospital. A letter from Telligen dated 1/23/25 stated that the PASARR screening submitted by the hospital would not be reviewed because psychiatric notes were missing. The social worker stated it was her responsibility to verify that PASARR was completed prior to admission and confirmed that she became aware on 8/14/25 that the resident did not have an approved Level 1 PASARR screening. The Facility Administrator was made aware of the concern on 8/14/25.
Failure to Provide Scheduled Showers and Personal Hygiene
Penalty
Summary
The facility failed to ensure that dependent residents’ personal hygiene needs were adequately met by offering and providing showers as scheduled. Resident #103 was assessed as totally dependent on staff for bathing and showers, and the care plan indicated daily bathing with showers twice weekly. The resident’s shower binder showed the resident was scheduled for showers on Wednesdays and Saturdays, but the documentation did not show that showers were provided or refused as required. The shower log provided for July and August showed only 2 showers in July and 2 showers through August 14, with one documented refusal in July. The DON confirmed the shower records were accurate and that the resident had received only those showers. Resident #88 was also assessed in MDS section GG as dependent on staff for showers and personal hygiene. The resident’s representative reported concerns that the resident did not receive appropriate personal hygiene and wore the same clothes for several days. The resident was observed wearing the same clothes on consecutive days, and the care plan did not show refusals to personal hygiene. Shower logs showed only 1 shower in July and one documented refusal in August. Staff stated the resident was supposed to receive showers twice weekly, and the unit manager confirmed the resident was not getting showers as required.
Failure to Turn and Reposition Resident With Stage 4 Sacral Wound
Penalty
Summary
The facility failed to provide the necessary treatment and services to promote healing for Resident #131, who had a Stage 4 sacral wound with an onset date of 7/16/24. Weekly wound assessments showed the wound worsened in the 8/14/24, 8/22/24, and 8/30/24 assessments. Review of the resident’s August 2024 documentation survey report showed multiple shifts in which GNAs documented that the resident was not turned or repositioned every two hours, including 8/1/24 Day, 8/8/24 Night, 8/10/24 Day, 8/14/24 Day, 8/19/24 Day, 8/21/24 Evening, 8/23/24 Day, 8/29/24 Night, and 8/30/24 Day/Evening. On other shifts, the GNAs did not document anything for the turn and reposition task, including 8/7/24 Day, 8/15/24 Day, 8/21/24 Day, 8/24/24 Day, 8/25/24 Day, 8/26/25 Day, and 8/31/25 Night. The DON was informed of the concern and acknowledged that the GNAs were not turning or repositioning every two hours for Resident #131.
Improper Oxygen Administration and Documentation
Penalty
Summary
The facility failed to provide the necessary treatment and services to promote healing for a resident with an oxygen order. Resident #12 had an order for oxygen at 2 liters per minute via nasal cannula every 24 hours as needed at bedtime, but during observation the resident was not in the room and the oxygen was set at 10 liters per minute. Staff #21 confirmed the current order in the chart as 2 liters per minute as needed at bedtime. During interview, the resident stated they used oxygen to sleep and when sick, and reported using 7 liters per minute at night to sleep comfortably. The ADON stated that nursing should monitor the liters per minute when a resident is using oxygen and, after reviewing the MAR/TAR, confirmed that nursing staff had not been documenting that the resident was receiving oxygen therapy as needed.
Failure to Follow Ordered Fall and Positioning Interventions
Penalty
Summary
The facility failed to provide individualized care based on assessments and physician orders for one resident who had a recent fall, a right clavicle fracture, and redness around the left eye. The resident had orders to wear a hipster padded brief every shift while awake for fall interventions, float heels when in bed, and wear a sling on the right arm. The care plan also noted that the resident refused to wear the ordered sling, but there was no care plan for refusals to the heel-floating order. Survey observations and record review showed that the resident was observed wearing regular briefs instead of the ordered hipster padded briefs, and at another observation was without the sling on the right arm and without heels floated while sleeping in bed. Staff #5 confirmed that the resident was not wearing the sling, was not wearing the hipster padded brief, and that the heels were not floated. Staff #5 also stated that documentation inaccurately indicated the resident was wearing the sling and hipster padded briefs, and acknowledged that the resident's heels were not floated.
Hand Hygiene Not Performed Between Removal of Contaminated Dressing and Wound Care
Penalty
Summary
Failure to use appropriate infection control practice of hand hygiene during wound care was identified during observation of a dressing change for a resident with multiple pressure ulcers. The resident had a facility-acquired stage 4 pressure ulcer of the sacrum and an unstageable ulcer of the right foot. During the wound care observation, staff performed hand hygiene, wore clean gloves, and removed the old sacral dressing, which was observed to have a yellow substance. After removing the contaminated dressing, staff did not perform hand hygiene before continuing the wound care. The wound was then cleaned with wound cleanser and Dankin solutions, Flagyl powder was applied, and a labeled calcium alginate dressing was placed on the sacrum. Staff performed hand hygiene only at the beginning of the task and again when leaving the room. During interview, staff stated that hand hygiene is expected after removal of a dirty dressing and acknowledged forgetting to perform that step. The DON was notified of the concern.
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Illustrative
What surveyors actually found near you
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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.
Illustrative
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Illustrative
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Nursing homes near Catonsville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Autumn Lake Healthcare At Catonsville | 0.9 mi | ★★★★★ | 41 | 0 |
| St. Joseph's Nursing Home | 0.9 mi | ★★★★★ | 17 | 0 |
| Forest Haven Nursing And Rehabilitation Ctr | 1 mi | ★★★★★ | 54 | 0 |
| Frederick Villa Healthcare | 1.9 mi | ★★★★★ | 62 | 0 |
| Ridgeway Rehab Center | 1.9 mi | ★★★★★ | 28 | 0 |
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