Autumn Lake Healthcare At Catonsville

Federal health inspectors cited AUTUMN LAKE HEALTHCARE AT CATONSVILLE in CATONSVILLE, MD for a deficiency under regulatory tag F-F0557 during a standard health inspection conducted on 2025-08-18.

Category: Resident Rights Deficiencies

The facility was found deficient in the following area: Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.

Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 23 deficiencies cited during this inspection of AUTUMN LAKE HEALTHCARE AT CATONSVILLE.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-22.

Federal health inspectors cited AUTUMN LAKE HEALTHCARE AT CATONSVILLE in CATONSVILLE, MD for a deficiency under regulatory tag F-F0558 during a standard health inspection conducted on 2025-08-18.

Category: Resident Rights Deficiencies

The facility was found deficient in the following area: Reasonably accommodate the needs and preferences of each resident.

Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 23 deficiencies cited during this inspection of AUTUMN LAKE HEALTHCARE AT CATONSVILLE.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-22.

Federal health inspectors cited AUTUMN LAKE HEALTHCARE AT CATONSVILLE in CATONSVILLE, MD for a deficiency under regulatory tag F-F0559 during a standard health inspection conducted on 2025-08-18.

Category: Resident Rights Deficiencies

The facility was found deficient in the following area: Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 23 deficiencies cited during this inspection of AUTUMN LAKE HEALTHCARE AT CATONSVILLE.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-22.

Federal health inspectors cited AUTUMN LAKE HEALTHCARE AT CATONSVILLE in CATONSVILLE, MD for a deficiency under regulatory tag F-F0584 during a standard health inspection conducted on 2025-08-18.

Category: Resident Rights Deficiencies

The facility was found deficient in the following area: Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 23 deficiencies cited during this inspection of AUTUMN LAKE HEALTHCARE AT CATONSVILLE.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-22.

Federal health inspectors cited AUTUMN LAKE HEALTHCARE AT CATONSVILLE in CATONSVILLE, MD for a deficiency under regulatory tag F-F0604 during a standard health inspection conducted on 2025-08-18.

Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies

The facility was found deficient in the following area: Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 23 deficiencies cited during this inspection of AUTUMN LAKE HEALTHCARE AT CATONSVILLE.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-22.

F 0641

Ensure each resident receives an accurate assessment.

Level of Harm - Minimal harm or potential for actual harm

Based on record review, and interviews, it was determined that the facility failed to accurately document a discharge Minimum Data Set (MDS) assessment in a Resident's medical record. This was found evident of 1 (Resident #135) of 60 residents reviewed in the survey. The findings include: On 8/11/25 at 1:47 PM, the surveyor reviewed Resident #135's medical record. The review revealed that Resident #135 was admitted to the facility in late September 2023 as a hospice respite patient.Further review revealed that on both 9/29/23 and 10/2/23 a progress note was written that described Resident # 135 being found in the sitting position on the floor next his/her bed. In both notes Resident #135 was assessed for injury. On 8/12/25 at 11:23 AM, the surveyor reviewed Resident #135's September and October 2023's Medication Administration Record (MAR). The review revealed that Resident #135 had two pain medications ordered and both were ordered as needed. The review also revealed no documentation to indicate either the Tylenol or Morphine were given. The orders were written for Tylenol 650mg to be given every 6 hours as needed and Morphine 5mg to be given every 4 hours as needed for pain.Next the surveyor reviewed Resident #135's discharge MDS assessment. The review revealed that Resident #135 was documented as having no falls since admission in section J1800. On further review of section J Resident #135 was documented as receiving a scheduled pain medication regimen in section J0100. On 8/12/25 at 1:06 PM, the surveyor conducted a phone interview with the MDS Coordinator, Staff #26. During the interview Staff #26 stated Resident #135 had documented falls and that the no falls was an error and needed a modification to correct

the error.On 8/12/25 at 1:53 PM, the surveyor conducted a follow-up phone interview with Staff #26. During

the interview Staff #26 confirmed that Resident #135 did not receive scheduled pain medications and the documentation was incorrect and was documented in error.

Residents Affected - Few

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/18/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Autumn Lake Healthcare at Catonsville

16 Fusting Avenue Catonsville, MD 21228

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

Federal health inspectors cited AUTUMN LAKE HEALTHCARE AT CATONSVILLE in CATONSVILLE, MD for a deficiency under regulatory tag F-F0656 during a standard health inspection conducted on 2025-08-18.

Category: Resident Assessment and Care Planning Deficiencies

The facility was found deficient in the following area: Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 23 deficiencies cited during this inspection of AUTUMN LAKE HEALTHCARE AT CATONSVILLE.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-22.

Federal health inspectors cited AUTUMN LAKE HEALTHCARE AT CATONSVILLE in CATONSVILLE, MD for a deficiency under regulatory tag F-F0658 during a standard health inspection conducted on 2025-08-18.

Category: Resident Assessment and Care Planning Deficiencies

The facility was found deficient in the following area: Ensure services provided by the nursing facility meet professional standards of quality.

Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 23 deficiencies cited during this inspection of AUTUMN LAKE HEALTHCARE AT CATONSVILLE.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-22.

Federal health inspectors cited AUTUMN LAKE HEALTHCARE AT CATONSVILLE in CATONSVILLE, MD for a deficiency under regulatory tag F-F0677 during a standard health inspection conducted on 2025-08-18.

Category: Quality of Life and Care Deficiencies

The facility was found deficient in the following area: Provide care and assistance to perform activities of daily living for any resident who is unable.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 23 deficiencies cited during this inspection of AUTUMN LAKE HEALTHCARE AT CATONSVILLE.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-22.

F 0684

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Level of Harm - Minimal harm or potential for actual harm

Based on record review, facility policy and interviews, it was determined that the facility failed to adequately document wounds and responses to treatment of skin conditions. This was found evident of 1 (Resident #138) of 2 residents reviewed for wounds. The findings include: On 8/14/25 at 11:58 AM, the surveyor reviewed Resident #138's medical record. The review revealed that Resident #138 had a past medical history of peripheral vascular disease and foot pain. On further review it was noted that the facility identified

a change of condition on 12/5/23. The change in condition was related to a new open wound on Resident #138's Left Lower Extremity (LLE). A skin assessment was done and noted Resident #138 had a vascular wound to his/her LLE. Nowhere in the change of condition or the skin assessment was the wound's size or characteristics documented. An order for wound care was written to on 12/5/23 for wound care that included, cleaning the wound, and applying a xeroform and kerlix wrap daily to the LLE. The next skin assessment was completed on 12/13/23 and again there was no documentation of the wound size or characteristics to the LLE vascular wound nor any indication that other wounds were present. On 12/14/23 two change of conditions were noted for Resident #138 regarding wounds. The first change of condition was written at 4:46 PM, about a new wound found on his/her right leg. The summary stated, the Resident's right leg dressing was wet and had a foul smell, and that the Resident's pain was reported 8/10. It further stated that there were generalized open areas noted on the right leg and in-between the toes. On the 2nd change of condition written at 11:36 PM, also referenced the new right lower leg wound, but also the previous wound on the LLE. The summary stated, the dressing on bilateral (both) lower extremities were soaked with serosanguinous drainage and had a foul smelling odor. It further stated that Resident #138's right 2nd two had drainage and was black in color. The plan stated was to send Resident #138 to the hospital per family's request. On 8/13/25 at 1:27 PM, the surveyor conducted an interview with the Regional Director of Nursing (RDON). During the interview the surveyor relayed the concern that if the skin condition/wound was not documented with characteristics and/or measurements weekly then how can the facility measure or know if the treatment is working or appropriate or if the wound is getting worse. The RDON agreed that the wound documentation did not have documentation of a full assessment and would look to see if there was additional documentation. The surveyor requested the facility's wound care policy Next the surveyor reviewed the policy titled, Documentation of Wound Treatments. Guide line number 2 stated, the following elements are documented as part of a complete wound assessment: a, type of wound, b, stage of wound, c, measurement , and d, description of wound characteristics. At the time of exit no additional wound assessment was provided.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/18/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Autumn Lake Healthcare at Catonsville

16 Fusting Avenue Catonsville, MD 21228

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

Federal health inspectors cited AUTUMN LAKE HEALTHCARE AT CATONSVILLE in CATONSVILLE, MD for a deficiency under regulatory tag F-F0693 during a standard health inspection conducted on 2025-08-18.

Category: Quality of Life and Care Deficiencies

The facility was found deficient in the following area: Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 23 deficiencies cited during this inspection of AUTUMN LAKE HEALTHCARE AT CATONSVILLE.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-22.

F 0697

and a re-assessment should have been completed after to evaluate effectiveness. At the time of exit no additional pain assessments were provided to the surveyor. Cross Reference F-F755

Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/18/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Autumn Lake Healthcare at Catonsville

16 Fusting Avenue Catonsville, MD 21228

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

Federal health inspectors cited AUTUMN LAKE HEALTHCARE AT CATONSVILLE in CATONSVILLE, MD for a deficiency under regulatory tag F-F0732 during a standard health inspection conducted on 2025-08-18.

Category: Nursing and Physician Services Deficiencies

The facility was found deficient in the following area: Post nurse staffing information every day.

Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 23 deficiencies cited during this inspection of AUTUMN LAKE HEALTHCARE AT CATONSVILLE.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-22.

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Resident's blood pressure and it was done by nursing judgement. The surveyor asked if a resident's medication was held without parameters if it would be the expectation for the staff to notify the provider?

The RDON stated that she would practice that way and was not able to say if the provider was notified of

the medications being held. On 8/14/25 at 10:34 AM, the surveyor interviewed Physician #27. During the

interview the physician stated he would expect to be notified if a medication was not being given. He further stated that if medications were recommended by a resident's specialist physician he would be responsible for coordinating medication regimens and need to be aware of medications being held. Cross Reference F-F697

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/18/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Autumn Lake Healthcare at Catonsville

16 Fusting Avenue Catonsville, MD 21228

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

Federal health inspectors cited AUTUMN LAKE HEALTHCARE AT CATONSVILLE in CATONSVILLE, MD for a deficiency under regulatory tag F-F0761 during a standard health inspection conducted on 2025-08-18.

Category: Pharmacy Service Deficiencies

The facility was found deficient in the following area: Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 23 deficiencies cited during this inspection of AUTUMN LAKE HEALTHCARE AT CATONSVILLE.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-22.

Federal health inspectors cited AUTUMN LAKE HEALTHCARE AT CATONSVILLE in CATONSVILLE, MD for a deficiency under regulatory tag F-F0812 during a standard health inspection conducted on 2025-08-18.

Category: Nutrition and Dietary Deficiencies

The facility was found deficient in the following area: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Scope/Severity Level F: widespread, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 23 deficiencies cited during this inspection of AUTUMN LAKE HEALTHCARE AT CATONSVILLE.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-22.

Federal health inspectors cited AUTUMN LAKE HEALTHCARE AT CATONSVILLE in CATONSVILLE, MD for a deficiency under regulatory tag F-F0814 during a standard health inspection conducted on 2025-08-18.

Category: Nutrition and Dietary Deficiencies

The facility was found deficient in the following area: Dispose of garbage and refuse properly.

Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 23 deficiencies cited during this inspection of AUTUMN LAKE HEALTHCARE AT CATONSVILLE.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-22.

F 0842 Level of Harm - Minimal harm or potential for actual harm

2) On 8/13/25 at 8:57 AM, while reviewing Resident #6 paper medical record on Unit C, the surveyor observed Resident #20 documentation in Resident #6's paper medical record. The documentation consisted of an appointment slip for a Urology appointment, a transportation form, and a consultation note.

The surveyor asked Registered Nurse (RN) #35 to make copies of the documents. While putting the documents back in Resident #6 chart, RN #35 realized the documents belonged in Resident #20 chart.

Residents Affected - Few

On 8/13/25 at 9:29 AM, the surveyor reported to the Regional Director of Nursing Resident #20 medical documentation was in Resident #6 paper chart. The Regional Director of Nursing verbalized the staff filed

the documentation in the wrong chart.

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/18/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Autumn Lake Healthcare at Catonsville

16 Fusting Avenue Catonsville, MD 21228

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

Federal health inspectors cited AUTUMN LAKE HEALTHCARE AT CATONSVILLE in CATONSVILLE, MD for a deficiency under regulatory tag F-F0880 during a standard health inspection conducted on 2025-08-18.

Category: Infection Control Deficiencies

The facility was found deficient in the following area: Provide and implement an infection prevention and control program.

Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 23 deficiencies cited during this inspection of AUTUMN LAKE HEALTHCARE AT CATONSVILLE.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-22.

Federal health inspectors cited AUTUMN LAKE HEALTHCARE AT CATONSVILLE in CATONSVILLE, MD for a deficiency under regulatory tag F-F0908 during a standard health inspection conducted on 2025-08-18.

Category: Environmental Deficiencies

The facility was found deficient in the following area: Keep all essential equipment working safely.

Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 23 deficiencies cited during this inspection of AUTUMN LAKE HEALTHCARE AT CATONSVILLE.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-22.

Federal health inspectors cited AUTUMN LAKE HEALTHCARE AT CATONSVILLE in CATONSVILLE, MD for a deficiency under regulatory tag F-F0919 during a standard health inspection conducted on 2025-08-18.

Category: Environmental Deficiencies

The facility was found deficient in the following area: Make sure that a working call system is available in each resident's bathroom and bathing area.

Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 23 deficiencies cited during this inspection of AUTUMN LAKE HEALTHCARE AT CATONSVILLE.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-22.

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and

the public.

Based on observation and interviews and review of contractor records, it was determined that the facility failed to keep a sanitary environment. This was found evident in the conference room, ice machine room, kitchen, laundry room and rehabilitation room during the survey. The findings include: On 8/13/25 at 5:43 AM, the surveyor observed vermin dropping located in the first floor conference room. On 8/14/25 at 6:10 AM, the surveyor reviewed the pest management company treatment documents. The surveyor noted that several recommendations were repeated throughout the treatment reports. The pest management company wrote they observed voids (holes) in the kitchen on 2/24/25, 7/16/25 and 7/25/25. On 7/25/25 the comment stated, one of the voids in the kitchen still needs to be sealed. It also stated broken tiles were found that were holding dirty water in breakage under the floor. The company also commented that this attracts roaches to the area. Additionally the company recommended improving sanitation procedures. This was recommended on 5/29/25, 7/16/25 and 7/24/25. On 7/24/25 the comments stated, poor sanitation throughout the kitchen and dish room area were observed. Due to sanitation conditions, this can create and attract roaches; better cleaning procedures are needed for staff to follow. On 8/14/25 at 7 AM, two surveyors took a tour of the facility. In the first-floor ice room a void in the wall where a plumbing pipe was entering the room was stuffed with steel wool. Additionally, what appeared to be a wet dirty towel was noted under the ice machine. On the back wall behind the machine there was debris, a few cup lids and a facemask on the floor. On 8/14/25 at 7:05 AM, the surveyors observed the kitchen. Several cracked tiles were noted on the floor in the hallway just outside the chemical room. On 8/14/25 at 7:07 AM, the surveyors observed the area under the dishwasher. A lid to a pitcher, a bowel, a piece of wrapper and debris were noted. On further observation vermin droppings were noted. Next the surveyor observed a French fry, wrappers and debris under the sink next to the drain. No French fries were being prepared during this

observation On the back wall under the stainless steel preparation table, located next to the oven, there was noted vermin droppings. The surveyor next observed the stainless steel preparation tables in the center of the kitchen. Both tables had water accumulation under them. The farther table had a piece of cut banana under it. No bananas were being prepped during the observations. On 8/14/25 at 7:14 AM, the surveyors observed the laundry area in the basement. Multiple corners of the walls had rusted broken metal trim with what appeared to be holes in them. Multiple sections of tile were broken. On 8/14/25 at 7:16 AM, the surveyors observed a bucket collecting drips from a leaking sink. Tiles were broken under the sink.

On 8/14/25 at 7:19 AM, the surveyors observed the clean laundry room. A chain of lint was noted alongside

the side wall. Behind a linen cart was a dried spill of brown substance, a bottle cap, a wrapper, and a shoe.

On 8/14/25 at 7:23 AM, the surveyors observed the rehabilitation department. Along the entrance wall vermin droppings were noted. Further up the wall a pistachio nut was noted. Debris, plastic cap and a ball were noted under the Air Condition (AC) unit. On 8/14/25 at 11:58 AM, the surveyor reviewed the

observations and concerns that the facility had accumulated debris, vermin droppings in multiple areas throughout the facility with poor sanitation practices. Cross Reference F-F925

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/18/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Autumn Lake Healthcare at Catonsville

16 Fusting Avenue Catonsville, MD 21228

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0925 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

mouse droppings; acknowledged the surveyors and stated that the contracted pest control company services the facility on a weekly basis.

The surveyor conducted a record review on [DATE REDACTED] at 2:15 PM of the All State Pest Management Service Inspection Reports for the months of [DATE REDACTED] and [DATE REDACTED]. All State Pest Management was the contracted company that serviced the facility for pest control. On the [DATE REDACTED] visit, the technician “inspected and treated all 4 nurses’ stations for occasional invaders; inspected and treated activity room for prior mice activity; deceased mouse was found under the refrigerator during the visit”. On the [DATE REDACTED] service visit, the technician “inspected and treated all 4 nurses’ stations, kitchen area and dishwasher room, rehab gym and nourishment rooms for occasional invaders”. On the [DATE REDACTED] service visit, the technician “inspected and treated kitchen area and dishwasher room, all 4 nurses’ stations, and rehab gym for occasional invaders; inspected and treated the country inn for prior mice activity; replenished RTUs (mouse bait stations) as needed”. On the [DATE REDACTED] service visit,

the technician “inspected and treated all 4 nurses’ stations and dining room for occasional invaders; inspected and treated the country inn office for prior mice activity”. On the [DATE REDACTED] service visit, the technician “checked logbooks; mice activity reported in room [ROOM NUMBER]; inspected and treated kitchen area and dishwasher room, and all 4 nurses’ stations for occasional invaders; inspected and treated room [ROOM NUMBER] for mice activity”.

On [DATE REDACTED] at 6:35 AM the survey team observed additional mouse droppings in the conference room behind boxes of copy paper. The Licensed Nursing Home Administrator (LNHA) and the Regional Clinical Nurse were notified of the mouse droppings and acknowledged the surveyors.

In an interview with the Licensed Nursing Home Administrator (LNHA) at 7:10 AM on [DATE REDACTED], the surveyor conveyed to the LNHA that there was a complaint submitted to the Office of Healthcare Quality (OHCQ) from a Resident’s family regarding a rodent in the facility. Additionally, the surveyor conveyed that

the All State Pest Management Service company found occasional invaders, mice, and evidence of mice activity during their weekly visits in various locations of the facility, including Resident rooms. This concern with pests and rodents was indicated on the pest management service inspection reports that were reviewed by the surveyor from the company’s service visits on [DATE REDACTED] through [DATE REDACTED]. The LNHA acknowledged the surveyor’s concerns regarding pests and rodents in the facility.

At the time of the survey exit no additional information was provided by the facility related to maintaining an effective pest control program.

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet