Autumn Lake Healthcare At Overlea
AUTUMN LAKE HEALTHCARE AT OVERLEA in BALTIMORE, MD — inspection on October 22, 2025.
Found 4 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
During the interview the surveyor requested documentation to show Resident #5's SPC flushes were done per recommendation in February, March and second half of April along with documentation of Resident #'s 5 SPC changes for January - May 2025. On 10/21/25 at 2:22 PM, the surveyor conducted a follow-up interview with the DON.
During the interview the DON confirmed that no flushes were documented as administered for the later part of January, February, March and half of April 2025 even though the recommendations were to do so.
She further stated that during that time different urology consult providers were coming into the building and that they all had different ways of communicating with the facility.
She stated that SPC changes were performed when the urology consultation provider came in to do consultation visits.
She confirmed that there was no documentation in Resident #5's medical record to indicate the SPC was changed after 12/28/25.
The DON stated she would have to reach out to the providers to get documentation that the catheters were changed.
On 10/22/25 at 12:18 PM, the surveyor conducted a telephone interview with urology/pelvic consult Provider Staff #6.
During the interview Staff #6 indicated that there are only a few reasons why the providers would change the SPC on the consultation visits, such as an initial change after placement or a complicated catheter. He further stated that if the provider changed the catheter, it would be documented in the progress note from that visit. He confirmed that unless the providers indicated they were going to change the catheter then it is the expectation that the facility would change the catheters per the Resident's individual plan of care. At the time of exit no documentation was provided to support that the SPC was changed for Resident #5 for January-May 26 of 2025 (on 5/26/25 hospital records documented it was changed) or flushes were provided February, March and second half of April.
Cross reference F-F842 1b) On 10/22/25 at 9:49 AM, the surveyor reviewed Resident #11's medical record the review revealed Resident #11 had a past medical history of obstructive and reflux uropathy, and overactive bladder. Resident #11 had a suprapubic catheter (SPC). On further review the surveyor noted an order was initiated on 12/30/22 that stated, change suprapubic foley (catheter) every 4 weeks on Friday night shift.
Next the surveyor reviewed Resident #11's Treatment Administration Records (TAR)s.
November of 2024 Resident #11's catheter was documented as changed on 11/1/24 and 11/29/24. On the December 2024's TAR the order was discontinued on 12/9/24 and on 12/11/24 the order was changed to change as needed.
There was no documentation that Resident #11's SPC was being changed in January - July's TARs.
The surveyor reviewed Resident #11's urology(provider that specializes in urinary tract system)/pelvic medical team consultation notes from visit on 11/15/24, 12/13/25, 12/27/24, 1/24/25 and 3/26/25.
All notes stated, Please perform routine exchange the SPC routinely every 4-6 weeks.
Nowhere in the note did it state that the SPC was exchanged. On further review the surveyor reviewed a progress note written on 12/10/24 by Registered Nurse (RN) #12.
The note stated that Staff reached out to Resident #11's Resident Representative (RP) after Resident #11 returned to the facility and informed Resident #11's RP that the SPC was changed monthly by the urology staff.
The surveyor noted that the urology staff had not seen Resident #11 monthly in 2025. On 10/22/25 at 10:05 AM, the surveyor requested documentation from the Director of Nursing (DON) demonstrating that Resident #11's SPC was changed per recommendations every 4-6 weeks. At the time of exit no documentation was provided to support that the SPC was changed for Resident #11 for January-July of 2025.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
10/22/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Autumn Lake Healthcare at Overlea
6116 Belair Road Baltimore, MD 21206
SUMMARY STATEMENT OF DEFICIENCIES
The surveyor reviewed Resident #11's urology/pelvic medical team consolation notes from visits on 11/15/24, 12/13/25, 12/27/24, 1/24/25 and 3/26/25.
All notes stated, Please perform routine exchange the SPC routinely every 4-6 weeks.
Nowhere in the note did it state that the SPC was exchanged. On 10/22/25 at 10:05 AM, the surveyor requested documentation from the Director of Nursing (DON) demonstrating that Resident #11's SPC was changed per recommendations every 4-6 weeks. On 10/22/25 at 11:47 AM, the surveyor conducted an interview with the DON and during the interview the DON stated she had reached out to the consult providers to request documentation for Resident #11's SPC changes. At the time of exit no documentation was provided to support that the SPC was changed for Resident #11 for January-July of
- Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
10/22/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Autumn Lake Healthcare at Overlea
6116 Belair Road Baltimore, MD 21206
SUMMARY STATEMENT OF DEFICIENCIES
Based on observations and interviews it was determined that the facility staff failed to ensure the shower rooms on the third floor were cleaned for the residents' use.
This deficient practice was evidenced in 2 (#A, #B) of 2 shower rooms on the third floor assessed for cleanliness during the complaint survey.The findings include:On 10/21/25 at 8:30 am during observation rounds on the third floor the surveyor observed a large stain on the floor under the sink along with water & stains around the commode in Shower Room B. In Shower Room A the surveyor observed multiple round brown stains on the floor in front of the sink and stains on the floor in the shower stall & in the area where the commode is located.On 10/22/25 at 10:12 am the surveyor observed the same round brown spots on the floor in front of the sink in Shower Room A, the same spots from the previous day.
The surveyor wet a paper towel with water and was able to remove one of the brown spots on the floor.On 10/22/25 at 10:14 am during an interview with Geriatric Nursing Assistant (GNA) #7 the surveyor asked how often the shower rooms are used by the residents. GNA #7 verbalized the showers are used daily; the residents either have a shower during the 7 am -3 pm shift or during the 3 pm - 11 pm shift.
The schedule was written on the assignment board located near the nurse's station.On 10/22/25 at 11:28 am during an interview with EVS Director #9 the surveyor asked how often the showers are cleaned. EVS Director #9 verbalized the showers should be cleaned daily. A deep cleaning of the showers during the weekend.
The mop heads are hard to get certain things off the floor.
They are working on getting new mopheads to clean the floors in the shower rooms.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
10/22/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Autumn Lake Healthcare at Overlea
6116 Belair Road Baltimore, MD 21206
SUMMARY STATEMENT OF DEFICIENCIES
The surveyor observed a hole in the handrail outside of room [ROOM NUMBER] & the handrail had a yellow screw that was not flush to the surface.
The surveyor observed two screws on separate sides of the handrail outside of the MDS Nurse's office that were not flush to the surface. On 10:26 AM the surveyor observed an unflushed screw in the handrail outside of room [ROOM NUMBER].
The surveyor observed unflushed nails in the handrail between the Storage Room & EVS Room, and the handrail was not secured to the wall.
The handrail shook when the slightest pressure was applied.
The handrail near the Central Supply Room was loose with a screw that was not flush to the surface.
On 10/22/25 at 11:16 AM the surveyor reported to the Administrator That there were multiple broken handrails and handrails that had screws that were not flush with the surface on the third floor.
The Administrator verbalized they were trying to secure the handrails with the screws.
The surveyor verbalized that the screws are not flush to the surface and has the potential to cause injury to a residents hand while using the handrail.
Facility ID: