Autumn Lake Healthcare at Loch Raven: Care Plan Failures - MD
Inspectors from the Centers for Medicare and Medicaid Services visited the facility at 8720 Emge Road in late April and reviewed 16 medical records for person-centered care plans. Two of those records had problems serious enough to document. Both pointed to the same failure: staff knew what a resident needed and wrote it down in a way that was essentially useless.
For the dialysis patient, identified in inspection records as Resident 7, the care plan that existed didn't say what type of dialysis the resident was receiving. It didn't say when treatment was scheduled. It didn't include the time frames for the treatment cycles. When the surveyor raised this with LPN Unit Manager 8 on April 28, the nurse's explanation was straightforward: "They never put the prescription inside of the care plan." Instead, staff would navigate to a general renal care plan template and select items from a menu. The result was a generic document that didn't reflect what was actually happening with this particular resident.
Peritoneal dialysis is not a routine medication pass. It involves infusing fluid into the abdominal cavity, allowing it to dwell, then draining it, in cycles that can run for hours. The timing matters. The type matters. A care plan that omits those details isn't a plan.
The second case involved a resident, identified as Resident 6, who had mobility limitations and required a Hoyer lift to get out of bed. A complaint filed before the inspection alleged the facility had only one Hoyer lift for all residents on a given floor, which meant the resident couldn't get up when he or she wanted to.
When the surveyor asked Unit Manager 13 about the Hoyer lift situation on April 29, the manager pushed back. Each floor had two lifts, she said, and the real issue wasn't equipment availability. Resident 6, she explained, didn't like the Hoyer lift and preferred a pivot transfer, where staff help a resident swing from bed to wheelchair using their remaining mobility. Physical therapy had prohibited that method for this resident.
That's a significant conflict. A resident who refuses the only approved transfer method, insists on one that physical therapy has ruled out, and can't get out of bed at the time he or she wants — that's exactly the kind of situation a person-centered care plan is supposed to address. The surveyor pointed out that Resident 6's care plan had interventions for resistance to care generally, but nothing specific to the Hoyer lift refusal, nothing about the pivot transfer prohibition, and nothing about how staff should navigate the standoff between what the resident wants and what physical therapy has allowed.
Unit Manager 13 denied that the facility had failed to get the resident out of bed in a timely way. But the care plan, as written, gave staff no documented guidance for handling the situation.
The surveyor brought both findings to the Director of Nursing and the facility administrator on the morning of April 30.
The violations were cited at the lowest level of harm, meaning inspectors found minimal harm or potential for actual harm rather than documented injury. But the care plan failures described here aren't paperwork technicalities. A dialysis resident's treatment schedule is not optional information. A mobility conflict that leaves a resident in bed longer than he or she wants to be is not a minor administrative gap.
Resident 6 wanted to get up. The equipment was disputed, the preferred transfer was prohibited, and the care plan addressed none of it. As of the inspection, that resident was still waiting for someone to write down a real plan.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Autumn Lake Healthcare At Loch Raven from 2026-04-30 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
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 6, 2026 · Our methodology
AUTUMN LAKE HEALTHCARE AT LOCH RAVEN in BALTIMORE, MD was cited for violations during a health inspection on April 30, 2026.
Two of those records had problems serious enough to document.
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.