Autumn Lake Healthcare at Catonsville: Record Mix-Up - MD
The inspection, completed August 18, 2025, was triggered by a complaint. What the surveyor found was straightforward: inside Resident 6's paper medical chart sat three documents that had nothing to do with Resident 6. A urology appointment slip. A transportation form. A consultation note. All of them belonged to Resident 20.
The surveyor asked Registered Nurse 35 to make copies of the documents. It was during that process, while the nurse was returning the papers to the chart, that she recognized they were in the wrong place.
Nobody had caught it before that moment.
On August 13, 2025, the surveyor reported the misfiling to the facility's Regional Director of Nursing. The director's response was brief. Staff had filed the documentation in the wrong chart. That was the explanation offered, and the record does not reflect anything more.
The violation was classified as causing minimal harm or potential for actual harm, and inspectors noted that few residents were affected. Those classifications sit at the lower end of the federal deficiency scale. But the records themselves, a urology appointment slip, a transportation form, a consultation note, are exactly the kind of documents that move care forward or stop it. A missed urology appointment because paperwork was lost in the wrong chart. A transportation arrangement that never connected to the right person. A specialist's consultation note that a treating nurse never saw because it was filed under someone else's name.
The inspection report does not say whether Resident 20's care was delayed or disrupted. It does not say how long the documents sat in the wrong chart before a surveyor happened to look. It does not say whether anyone went looking for those records before they were found.
Paper medical records in nursing homes carry particular risk precisely because they depend on human hands at every step. A document placed in the wrong folder stays there until someone pulls the folder for a reason. In a facility where residents may be seen by multiple nurses across multiple shifts, a misfiled consultation note can sit untouched for days.
Autumn Lake Healthcare at Catonsville is located at 16 Fusting Avenue. The facility's identification number with the Centers for Medicare and Medicaid Services is 215097.
The Regional Director of Nursing told the surveyor that staff filed the documentation in the wrong chart. What the facility did next, whether it audited other charts for similar errors, whether it reviewed how paper records are sorted and filed, whether it identified how long Resident 20's documents had been missing from Resident 20's chart, is not described in the inspection report.
Resident 20 had a urology appointment. Someone arranged transportation. A specialist wrote a consultation note. At some point, all three of those documents ended up in a folder with another person's name on it, and stayed there until a federal surveyor asked a nurse to make copies.
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.
Corrections: We strive for accuracy in everything we publish. If you believe any fact in this article is incorrect, please contact us with details, and we will review and correct it promptly.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: October 17, 2026 · Our methodology
AUTUMN LAKE HEALTHCARE AT CATONSVILLE in CATONSVILLE, MD was cited for violations during a health inspection on August 18, 2025.
The inspection, completed August 18, 2025, was triggered by a complaint.
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.