Autumn Lake Healthcare at Catonsville: Pain Assessment Failures - MD
The patient, identified in federal inspection records only as Resident 135, was admitted to Autumn Lake Healthcare at Catonsville in late September 2023. He or she had a history of abnormal weight loss and senile degeneration of the brain. A progress note from the day after admission described the resident as very confused while awake and not easily redirected.
Two pain medications had been ordered: Tylenol 650mg every six hours as needed, and Morphine 5mg every four hours as needed. Neither was documented as given during September or October 2023. But six doses of morphine were recorded in the controlled drug administration records, meaning the medication was pulled and presumably administered, with no corresponding pain assessments to show why it was given or whether it worked.
The gap between what the records showed and what they were supposed to show is what inspectors spent two days untangling.
The facility's own pain monitoring forms, attached to the medication administration records, listed numbers in the daily tracking column: a 1 on September 28, a 1 on September 29, a 1 on September 30, a 0 on October 1, a 1 on October 2. When the surveyor asked the Regional Director of Nursing what those numbers meant, specifically in the context of a resident who was documented as unable to communicate, she said the notation referred to a "Pain Indicator" and said she would look to see if there was a pain code. She then said she would look for pain evaluations to see how the resident's pain had been assessed.
There was a pain evaluation from September 29. It noted that Resident 135 appeared different than usual behavior, and checked yes to ten of the thirteen listed behavioral pain indicators. When asked whether the resident could indicate the location and characteristics of the pain, the answer was no.
Three days later, on October 2, someone completed a pain interview assessment for Resident 135. The instructions on that form stated clearly: complete the pain assessment interview if the resident is able to communicate appropriately. If the resident is rarely or never understood, skip to section F. The assessment indicated the interview should not be completed. So far, that was correct. But Section F asked whether a staff assessment for pain should be conducted. The answer recorded was no. Nothing more was done.
A resident who cannot speak for themselves, who is on hospice, who is showing the majority of observable pain behaviors, and the documented answer to whether staff should assess their pain was no.
The Assistant Director of Nursing, reviewing the controlled drug records with the surveyor on August 12, confirmed that a pain assessment should have been completed every time morphine was given, and a reassessment should have followed each dose to evaluate whether it was effective. By the time inspectors left the facility, no additional pain assessments had been produced.
The facility's own pain management policy stated that staff would use a pain assessment tool appropriate for the resident's cognitive status. For a resident who was confused, non-communicative, and showing ten behavioral indicators of pain, that meant an observational assessment, not a verbal interview. The verbal interview tool was the wrong instrument, and when staff reached the section that would have triggered the correct one, they marked it as unnecessary and stopped.
What the inspection record does not contain is any explanation for how the numbers on the daily monitoring forms were generated, who wrote them, or what they were meant to represent. The Regional Director of Nursing said she would look into it. The surveyor's review found no basis for them.
Resident 135 was a hospice patient, which means the clinical goal was comfort. The morphine existed for that reason. Whether it provided any comfort, whether the doses given were enough, whether the resident was in pain when the medication wasn't given, none of that was documented in any form the facility could produce during the inspection.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Autumn Lake Healthcare At Catonsville from 2025-08-18 including all violations, facility responses, and corrective action plans.
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: October 16, 2026 · Our methodology
AUTUMN LAKE HEALTHCARE AT CATONSVILLE in CATONSVILLE, MD was cited for violations during a health inspection on August 18, 2025.
The patient, identified in federal inspection records only as Resident 135, was admitted to Autumn Lake Healthcare at Catonsville in late September 2023.
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.