Autumn Lake Healthcare: Care Quality Failures - MD
The inspection, conducted on November 24, 2025, flagged problems with the facility's discharge documentation under a deficiency tag tied to medical record accuracy. Inspectors had reviewed forms tracking residents discharged within the previous six months. Those forms indicated the residents left for home.
The nursing home administrator, identified in the report only as NHA Staff #1, told the surveyor that the MDS Coordinator had made a mistake. "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 version.
Inspectors returned for a follow-up interview with the same administrator at 4:05 that afternoon. This time, the answer was different. There was no additional information to provide, the administrator said. The residents had been discharged home after all.
The report does not say how many residents were involved, only that "few" were affected. It does not say whether the residents were ever located, whether their actual discharge destinations were confirmed, or whether the discrepancy affected their care in any way. The harm level was rated minimal.
What the record does show is a facility that, within the span of a few hours, offered two contradictory explanations for the same documentation, with no apparent resolution between them. The first answer blamed a staff member. The second answer abandoned that claim without explanation.
Discharge records exist, in part, so that care can follow a patient from one setting to the next. When a resident leaves a nursing facility, whoever receives them, whether a family member at home or a clinical team at a hospital, depends on accurate transfer information. A form that says home when the answer is hospital, or hospital when the answer is home, is not a paperwork problem. It is a gap in the chain of care.
The inspection report offers no indication that the facility resolved which answer was true.
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.
Inspectors had reviewed forms tracking residents discharged within the previous 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.