Autumn Lake Healthcare at Cherry Lane: Records Failures - MD
A doctor ordered daily weights for Resident 163 starting January 30, 2025, with instructions to call the physician if the resident gained more than two pounds in a day or five pounds over five days. The order ran through February 12. Over those 14 days, the Treatment Administration Record showed staff marking the task complete every single night, with two exceptions when the resident refused.
Three weights were actually documented in the electronic medical record: January 30, February 3, and February 12.
When inspectors reviewed the paper chart on August 1, no additional weights appeared there either. The Director of Nursing told inspectors that weights were kept in a binder on the nursing unit. Inspectors walked to the 2A/2B unit and found the binder. Resident 163 had no daily weight log inside it.
The Unit Manager and Staff Educator, an RN, said the weight log would be stored with the resident's chart in Medical Records. The Medical Records Coordinator said there were no additional records for Resident 163. Everything, she told inspectors, would already be in the paper chart that had been provided.
Nine minutes later, the Unit Manager produced the log.
She said she had found it in the previous unit manager's office, a room that was not currently being used. The log was curled into a circle and could not lie flat. When inspectors went to see for themselves, they found the weight log loose on a rolling rack for file folders, rolled up alongside weight logs for other residents, with nothing holding any of it together.
The complaint that triggered the inspection had come from someone who reported the facility was not obtaining the ordered daily weights for Resident 163. That complaint was filed in July. The inspection took place August 1.
The second finding involved a different resident and a different kind of missing record.
Resident 137 told inspectors on August 12 that when they were admitted to the facility, staff took photographs without asking for consent. The Director of Nursing explained that residents are asked about photo consent when the admission packet is completed at intake, and that the Admissions Office would have that paperwork.
The Admissions Director told inspectors she had already searched for Resident 137's admission packet earlier that same day, at the Administrator's request, and could not find it. She explained that older admission packets were being stored in a room across the hall from her office, while more recent records had been moved into the electronic medical record system.
The packet for Resident 137 was in neither place.
When inspectors spoke with the Administrator, he said they had been unable to locate the admission packet. Then he offered a theory: the resident had probably refused to sign it.
Inspectors asked whether a refusal would have generated its own documentation. The Administrator agreed that it would. He confirmed no such documentation existed.
There was no signed consent form. No record of a refusal. No admission packet. Just a resident's account of being photographed without permission and an administrator's guess about what might explain the gap.
Inspectors cited the facility for failing to ensure medical records were complete, readily accessible, and organized. The deficiency was classified as causing minimal harm or potential for actual harm, and affected few residents.
The weight order for Resident 163 had a clear clinical purpose: catch fluid retention early enough to act on it. Staff initialed the nightly task as done. The log that would have shown whether it was actually done spent weeks rolled up in an empty room.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Autumn Lake Healthcare At Cherry Lane from 2025-08-13 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
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Last verified: November 4, 2026 · Our methodology
AUTUMN LAKE HEALTHCARE AT CHERRY LANE in LAUREL, MD was cited for violations during a health inspection on August 13, 2025.
The order ran through February 12.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.