Autumn Lake Bridgepark: No Correction Plan Filed - MD
The violations at Autumn Lake Healthcare at Bridgepark continued for at least two months before federal inspectors discovered them during a November complaint investigation. The resident, who relies entirely on nursing staff for care, had been hospitalized for facial and head swelling.
Resident #1 requires total assistance with all daily activities and receives nutrition through a feeding tube. The person was admitted with multiple serious conditions including complete ventilator dependence and a tracheostomy.
On September 5, a physician ordered nurses to give the resident Propranolol Hydrochloride, a cardiovascular medication, every eight hours to treat tachycardia. The order included a critical safety instruction: hold the medication if the resident's heart rate falls below 100 beats per minute.
Medication administration records from September and October show nurses signing off on doses without documenting the resident's heart rate. They gave the medication without confirming whether the resident's pulse met the minimum threshold required by the doctor's order.
The nursing staff also administered the medication incorrectly. While the physician ordered Propranolol to be given "by mouth," nurses were actually delivering it through the resident's gastrostomy tube. They never corrected the route of administration in the medical record.
During the inspection, the Director of Nursing told investigators she was unaware that staff were failing to document pulse rates before giving the cardiovascular medication. She also didn't know they were administering it through the feeding tube instead of by mouth as ordered.
The violations came to light after someone filed a complaint alleging the resident was not receiving quality care at the facility. Inspectors reviewed the complaint on November 13 and immediately began examining the resident's medical records.
Propranolol is commonly prescribed to slow rapid heart rates, but giving it to someone whose pulse is already too low can cause dangerous complications. The physician's order to check the heart rate before each dose and hold the medication when necessary was designed to prevent such risks.
The resident's hospitalization for facial and head swelling occurred sometime after the medication violations began. The inspection report does not specify whether the swelling was related to the medication errors.
Federal inspectors classified the violation as causing minimal harm or potential for actual harm. The finding affects multiple residents at the facility, though the inspection report details problems for only one person.
The case illustrates how basic safety protocols can break down in nursing homes. Taking a pulse rate is a fundamental nursing skill, and following physician orders precisely is a core responsibility of licensed staff.
The Director of Nursing's lack of awareness suggests inadequate oversight of medication administration practices. Nurses were making critical decisions about a life-sustaining medication without following the safety checks ordered by the resident's doctor.
The resident remains completely dependent on nursing staff for survival, requiring mechanical ventilation around the clock and receiving all nutrition through the feeding tube. Any medication error could have serious consequences for someone so medically fragile.
Autumn Lake Healthcare at Bridgepark must submit a plan of correction to continue participating in Medicare and Medicaid programs. The facility has not yet responded to the violations or explained how it will prevent similar medication errors in the future.
The inspection was completed November 13, but the problems with heart medication administration had been occurring for months before anyone noticed.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Autumn Lake Healthcare At Bridgepark from 2025-11-13 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 BRIDGEPARK in BALTIMORE, MD was cited for violations during a health inspection on November 13, 2025.
The resident, who relies entirely on nursing staff for care, had been hospitalized for facial and head swelling.
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.