Autumn Lake Healthcare at Summit Park: Lab Test Failure - MD
When federal inspectors reviewed the chart for the resident identified as Resident 120 on August 18, 2025, they found a documented change in condition from June 17, 2025. The resident had experienced a change in mental status with paranoid delusions. The following day, June 18, a physician ordered a urinalysis to rule out a urinary tract infection as the cause.
There were no lab results in the chart. No test had been run.
There was also no documentation that the resident had refused.
The Director of Nursing, when interviewed that afternoon, offered an explanation: the resident had declined the test. When inspectors asked him to produce documentation of that refusal, he said there was none.
That was the entirety of the facility's account. A verbal claim, made two months after the fact, with nothing in the record to support it.
Urinary tract infections are among the most common and most dangerous conditions affecting nursing home residents. In older adults, and particularly in residents with cognitive impairment or dementia, a UTI frequently does not present with the classic symptoms of burning or frequency. Instead, it can surface as sudden confusion, agitation, or behavioral changes, including paranoid thinking. A physician who orders a urinalysis after observing those symptoms is doing exactly what the clinical situation calls for. The test exists to answer a question that cannot be answered any other way.
Resident 120's chart showed the question was asked. There is no record that anyone tried to answer it.
The inspection was a complaint survey, meaning someone had raised a concern about care at Autumn Lake Healthcare at Summit Park before inspectors arrived. Investigators reviewed 27 residents' records during the course of the survey. The lab test failure was documented for one of them.
Inspectors cited the deficiency under the federal standard requiring facilities to provide timely, quality laboratory services to meet residents' needs. The level of harm was classified as minimal harm or potential for actual harm, the lower end of the federal harm scale. It affected a small number of residents.
What the classification does not capture is the gap between what the record shows and what the Director of Nursing said. The physician's order exists. The documented change in condition exists. The absence of results exists. The absence of any refusal documentation exists. The DON's explanation, offered more than two months after the test was due, exists only as something he said to inspectors in an interview.
Inspectors raised the concern with the DON on August 18 and again at the survey exit on August 27. The inspection report does not indicate that any corrective documentation was produced in the intervening nine days.
A urinary tract infection left untreated in an elderly resident can progress to a kidney infection, then to sepsis, a systemic response that is frequently fatal in nursing home populations. Whether Resident 120 had a UTI, whether the paranoid delusions resolved, whether anyone went back to the physician to report that the ordered test had never been completed, none of that is in the inspection report.
The record ends where the order was placed, in June, and picks up again in August when an inspector noticed the gap.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Autumn Lake Healthcare At Summit Park from 2025-08-27 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.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: October 3, 2026 · Our methodology
AUTUMN LAKE HEALTHCARE AT SUMMIT PARK in CATONSVILLE, MD was cited for violations during a health inspection on August 27, 2025.
The resident had experienced a change in mental status with paranoid delusions.
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.