Autumn Lake Summit Park: Wrong Meds Given to Residents - MD
Federal inspectors documented both medication errors during an August complaint investigation at the facility on Frederick Road. The errors occurred months apart but revealed similar problems with resident identification and dosage verification.
The insulin mistake happened on March 4, when Licensed Practical Nurse Staff #22 gave 4 units of Lispro to Resident #52 instead of the intended patient. Progress notes from that evening stated the error occurred due to "wrong identification of resident picture by name."
Staff discovered the mistake and immediately notified the physician and supervisor. The resident's blood sugar was monitored every six hours as a precaution. At 5:39 PM, blood sugar measured 107, rising to 113 by 11:54 PM. The resident remained alert and showed no signs of hypoglycemia or hyperglycemia.
The facility's incident report confirmed Staff #22 had administered medication to the incorrect resident. The nurse was placed on three-day reorientation following the error and completed additional competency training on March 11.
A separate medication error involved Resident #105, who received twice the prescribed dose of Clonazepam, a controlled substance used to treat seizures. On November 10, 2024, the resident received 2 mg instead of the ordered 1 mg dose.
The error was discovered during the medication count at shift change on November 9 at 11 PM. Staff #23, the Licensed Practical Nurse who administered the medication, found the tablets came in 1 mg doses, meaning only one tablet should have been given instead of two.
Medical staff immediately placed orders to hold the next Clonazepam dose and monitor vital signs every shift. The resident required neurological checks every 24 hours as a safety measure. The Nurse Practitioner was notified of the overdose.
Resident #105's representative confirmed the medication error occurred in November 2024 during an interview with inspectors. The resident had been prescribed Clonazepam 0.5 mg every eight hours via feeding tube for seizures since October 19. The original order was discontinued November 9, with a revised order specifying "PLEASE GIVE ONLY ONE TABLET."
Both errors prompted facility investigations and staff education. The Director of Nursing confirmed the Clonazepam error during inspector interviews, stating medication error protocols were followed and staff received additional training.
The Assistant Director of Nursing explained that Staff #22's insulin error resulted from failure to properly identify the resident before administration. The nurse underwent retraining on resident identification procedures and medication safety protocols.
Federal regulations require nursing homes to prevent significant medication errors that could harm residents. The facility's two documented errors occurred despite existing policies requiring staff to verify patient identity and medication dosages before administration.
Complaint #330032 regarding the insulin error covered an extended period from February 20, 2024, through August 15, 2025, suggesting ongoing concerns about medication safety at the facility.
Complaint #330061 specifically alleged Resident #105 received an incorrect medication dose, prompting the federal investigation that uncovered both errors.
The Clonazepam overdose was particularly concerning because the medication is a controlled substance with specific dosing requirements. Progress notes showed staff initially failed to recognize the tablets' actual strength, leading to the double dose administration.
Both residents' families were notified of the medication errors. Resident #52's family received notification the same day as the insulin mistake, while Resident #105's representative was aware of the November seizure medication error.
The facility's investigation statements revealed Staff #23 discovered the Clonazepam error during routine narcotic count procedures at shift change. This suggests the error might have gone undetected without the controlled substance verification process.
Staff education following both incidents focused on proper resident identification and medication verification procedures. However, the errors occurred months apart, indicating systemic issues with medication administration protocols.
The Director of Nursing confirmed both medication errors were substantiated through the facility's investigation process. Additional competency testing was completed for the nurses involved in both incidents.
Inspectors found the facility failed to prevent significant medication errors affecting two out of six residents reviewed during the complaint investigation. Both errors resulted in minimal harm but demonstrated potential for serious adverse outcomes.
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: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
AUTUMN LAKE HEALTHCARE AT SUMMIT PARK in CATONSVILLE, MD was cited for violations during a health inspection on August 27, 2025.
Federal inspectors documented both medication errors during an August complaint investigation at the facility on Frederick Road.
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.