Autumn Lake Healthcare: Medication Error Risks - MD
The nursing home administrator, identified in inspection records only as NHA Staff #1, told the surveyor that the MDS Coordinator had filled out the forms incorrectly. "My MDS Coordinator completed the form and likely put the wrong discharge information," the administrator said. "The residents were discharged to hospital, let me look into it."
That was the first story.
Later the same afternoon, at 4:05 p.m., the inspector followed up. The administrator no longer had additional information to offer, and the account had shifted. The residents, the administrator now said, were discharged home after all, the same destination the forms had listed from the start.
No explanation was offered for the reversal. No documentation was provided to clarify which version was accurate. The inspection report does not indicate whether the facility ever produced records confirming where the residents actually went.
The deficiency was cited under F0842, which covers the accuracy and completeness of resident records. Inspectors classified the level of harm as minimal or potential harm, with few residents affected.
The complaint inspection was conducted November 24, 2025, at the 215330-licensed facility. A plan of correction was not included in the publicly available inspection documents.
What the records show is a facility that, within the span of a single afternoon, offered inspectors two contradictory accounts of where its former residents ended up. Whether those residents went home or to a hospital remains, based on what inspectors were able to obtain, an open question.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Autumn Lake Healthcare Post-acute Care Center from 2025-11-24 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: August 4, 2026 · Our methodology
AUTUMN LAKE HEALTHCARE POST-ACUTE CARE CENTER in BALTIMORE, MD was cited for violations during a health inspection on November 24, 2025.
"My MDS Coordinator completed the form and likely put the wrong discharge information," the administrator said.
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.