Autumn Lake Healthcare: Unnecessary Drug Violations - MD
During a November 2025 complaint inspection, surveyors reviewed a form listing residents discharged within the last six months. The form indicated those residents had gone home. When the nursing home administrator, identified in the report as staff member one, was asked about it, the explanation was immediate: the MDS Coordinator had filled out the form and "likely put the wrong discharge information." The residents, the administrator said, had actually been discharged to a hospital. "Let me look into it," the administrator added.
Inspectors returned later that afternoon. At 4:05 p.m., they asked for whatever additional information the administrator had found.
There was none. And the story had changed.
The administrator now said the residents were discharged home after all, the same answer the form had given in the first place. No explanation for the reversal. No documentation offered to support either version.
The deficiency was cited under the federal tag governing medical records, at a harm level described as minimal harm or potential for actual harm, affecting a few residents.
What the inspection record does not resolve is which account is true. The form says home. The administrator first said hospital, then said home. The MDS Coordinator, whose name does not appear in the report, was described as the likely source of the error in the first telling and was not mentioned in the second.
Discharge destination is not a minor clerical detail. Where a resident goes when they leave a nursing home determines what follow-up care they receive, who is responsible for them, and whether anyone is looking for them if something goes wrong.
The records at Autumn Lake Healthcare offered two answers to that question. By the end of the inspection, nobody had settled on one.
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.
During a November 2025 complaint inspection, surveyors reviewed a form listing 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.