Autumn Lake Healthcare: Care Plan Failures - MD
Inspectors visiting Autumn Lake Healthcare Post-Acute Care Center on November 24, 2025 reviewed records for residents discharged within the last six months. The records indicated those residents had been discharged home.
When the nursing home administrator, identified in the report as NHA staff #1, was asked about the discharges, the explanation shifted immediately. The administrator told the surveyor that the MDS Coordinator had "likely put the wrong discharge information" on the form and that the residents had actually gone to the hospital. "Let me look into it," the administrator said.
That follow-up never produced anything.
Later the same afternoon, at 4:05 p.m., the surveyor returned for more information. The administrator's answer had changed again. There was "no other information," the administrator said. The residents were discharged home.
The inspection cited the deficiency under F0842, which covers the accuracy and completeness of resident records. CMS rated the level of harm as minimal or potential for actual harm, with few residents affected.
What the report leaves unresolved is whether the records were wrong the first time the administrator looked at them, or wrong by the time the conversation ended. The administrator initially said the MDS Coordinator made an error and that the residents went to a hospital. Hours later, with no additional investigation apparently conducted, the answer was the opposite: the records were right, and the residents went home.
The facility is located at 5009 Frankford Avenue in Baltimore. The inspection was completed November 24, 2025, and the report was printed April 13, 2026.
No explanation for the reversal appears anywhere in the inspection record.
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: 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: September 19, 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.
Inspectors visiting Autumn Lake Healthcare Post-Acute Care Center on November 24, 2025 reviewed records for residents discharged within the last six months.
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.