Autumn Lake Healthcare At Loch Raven
AUTUMN LAKE HEALTHCARE AT LOCH RAVEN in BALTIMORE, MD — inspection on April 30, 2026.
Found 6 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
The surveyor asked how many times had this chair system been used by residents being moved from the 2nd floor to the 1st floor for visitation purposes.
The Administrator stated that the emergency chair system was not used because 2nd floor residents and their visitors did not require the system when the facility's elevator was malfunctioning.
The surveyor also asked if there were any complaints from family not being able to visit residents on the 2nd floor when the facility's elevator was malfunctioning.
The Administrator stated that he was unaware of any complaints about the facility's elevator being inoperative.
The surveyor pointed out that OHCQ received two complaints from family members of residents residing on the 2nd floor not being able to visit their family member when the facility's elevator was inoperative.
The surveyor also pointed out that the emergency plan does not provide a plan for visitation.
The Administrator provided no additional documentation regarding the plan to provide for visitation for 2nd floor residents when the facility's elevator is inoperable.
215090 04/30/2026
Autumn Lake Healthcare at Loch Raven 8720 Emge Road Baltimore, MD 21234
The surveyor reviewed the statements and interviews concerning the incident.On 04/29/26 at 10:30 am during an interview with Administrator #1, the surveyor asked who completed the investigation.
Administrator #1 verbalized they completed the investigation.
The surveyor asked who was initially made aware of the alleged incident.
Administrator #1 verbalized Corporate Representative #12 was the first point of contact about the alleged incident.
The surveyor reported there was not a statement in the investigation from Corporate Representative #12.
The Administrator looked through the investigation and confirmed there was no statement from Corporate Representative #12.
The surveyor asked Administrator #1 to explain the process they use a complete an investigation.
Administrator #1 verbalized they interview the parties involved, see if there are any witnesses, look to see who was staffed during the date the alleged incident occurred.
They also interview the resident's roommate. If there were no witnesses, they interview other residents who were in proximity. 2. On 04/30/26 at 11:38 am a review of the facility's investigation concerning the self-report about Resident #2 that was submitted on 12/04/25 at 3:32 pm. Resident #2 reported that on 12/03/25 during 3:00 pm - 11:00 pm shift someone wearing blue put their hand by their face & over their mouth. GNA #9 was identified as the alleged perpetrator.On 04/30/26 at 12:24 pm a review of the staffing sheet during the time of the alleged incident revealed GNA #10 and GNA #11 worked on the unit where the alleged incident occurred.
There was not a statement or interview from GNA #10 or GNA #11.
Prior to reviewing the investigation, the surveyor provided Director of Nursing #2 and Regional Nurse #6 the opportunity to review the investigation to ensure all the necessary documents were available for the surveyor to review.
215090 04/30/2026
Autumn Lake Healthcare at Loch Raven 8720 Emge Road Baltimore, MD 21234
During the review of the residents that smoke and reside on the 2nd floor, the surveyor discovered that 5 of the 10 residents didn't receive a quarterly smoking assessment.
Residents (#1, #11, #13, and #15) did not have a smoking assessment since May 2025. Resident #16 did not have any smoking assessments during his/her stay in the facility. On 4/28/26 at 1:15pm, the surveyor interviewed the Director of Nursing (DON) and Unit Manager #8 regarding the facility's policy on the frequency for when residents are assessed for smoking safety.
Unit Manager #8 stated that residents that are identified as smoking are assessed quarterly for smoking safety.
The surveyor pointed out that 5 of the 10 residents affected by the facility's inoperative elevator had not had a smoking assessment quarterly. In fact, one of the residents had no evidence of the facility providing an smoking assessment for the resident during his/her stay.
The DON reviewed the resident records and confirmed the identified residents did not receive a quarterly smoking assessment.
215090 04/30/2026
Autumn Lake Healthcare at Loch Raven 8720 Emge Road Baltimore, MD 21234
The surveyor asked Unit Manager #13 about the number of hoyer lifts in the facility.
Unit Manager #13 stated that each floor of the facility had two hoyer lifts.
The surveyor informed Unit Manager #13 of Resident #6's concern that he/she were unable to get out of bed at a desirable time because of the lack of hoyer lifts on the 2nd floor.
Unit Manager #13 denied the facility's inability to provide timely transfer of the resident from the bed to his/her wheelchair at his/her desired time.
Unit Manager #13 stated that Resident #6 does not like the hoyer lift and prefers to be transferred from the bed to the wheelchair by pivoting.
Unit Manager #13 further stated that the resident was prohibited from pivoting transfer from the bed to the wheelchair by physical therapy.
The surveyor pointed out that Resident #6's care plan does not have interventions for the resident's resistance to the hoyer lift and his/her insistence on pivot transfer from the bed to the wheelchair despite prohibition from physical therapy.
On 4/30/26 at 9:00am, the surveyor informed the Director of Nursing and Administrator of the lack of a person centered care plan for Resident #6.
- On 04/28/26 at 11:45 am a review of Resident #7's electronic health record (EHR) revealed the
resident was ordered to receive peritoneal dialysis. A review of the resident's care plans revealed the resident did not have a person-centered care plan for the peritoneal dialysis treatment.
The care plan that was initiated for dialysis did not indicate what type of treatment the resident was receiving.
Also, the care plan did not include when the resident was scheduled to receive the treatment or the time frames for the cycles.
On 04/28/26 at 1:34 pm during an interview with LPN Unit Manager #8 the surveyor reported the resident did not have a person-centered care plan for their dialysis treatment. LPN Unit Manager #8 verbalized they never put the prescription inside of the care plan.
They go to the renal care plan & click the things that would be included in the resident's care.
They have a generalized care plan.
215090 04/30/2026
Autumn Lake Healthcare at Loch Raven 8720 Emge Road Baltimore, MD 21234
minimal harm to include the census on the unit when the staff sheets were completed.
This deficient practice was evidenced in 19 of 19 staffing sheets reviewed during the complaint survey.The findings are:On
shift revealed the census was not included on the assignment sheet.
The assignment sheet was reviewed by the surveyor to ascertain which staff was working during the time of an alleged incident of abuse.On 04/30/26 at 2:15 pm a review of the staffing sheets for Unit 2 dated 12/04/25 - 12/09/25 for 7:00 am - 3:00 pm, 3:00 pm - 11:00 pm, and 11:pm - 7:00 am revealed the assignment sheets did not include the census. On 04/30/26 at 4:37 pm during an interview with Scheduling Manager #14 the surveyor asked who was responsible for completing the assignment sheets on the nursing units.
Scheduling Manager #14 verbalized they were not sure who completed the assignment sheets on the units.
They were not aware the assignment sheet needed to include the census.
Director of Nursing #2 verbalized during the previous survey they were not told the census needed to be included on the assignment sheet.
215090 04/30/2026
Autumn Lake Healthcare at Loch Raven 8720 Emge Road Baltimore, MD 21234
The surveyor was not provided documentation to verify the resident received a shower or bed bath on 10/17/25, 10/21/25, and 10/24/25.
During an interview with Director of Nursing #2 they verbalized when a resident receives a shower it is documented on a skin sheet.
The surveyor asked who ensures the showers are being provided.
Director of Nursing #2 verbalized the nurse assigned to the resident, the unit manager, and they would as she collects the shower sheets.
The surveyor asked where it was documented when a resident refuses a shower.
Director of Nursing #2 verbalized it would be documented in the plan of care and the shower sheet when a resident refused a shower.
The surveyor did not receive documentation Resident #5 received a shower or bed bath on 10/17/25, 10/21/25, and 10/24/25.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.