Complaint Investigation

Autumn Lake Healthcare At Baltimore Washington

October 30, 2025 · Glen Burnie, MD · 313 Hospital Drive

Citations 1

CMS Rating 2/5

Beds 129

Provider ID 215316

Healthcare Facility

Autumn Lake Healthcare At Baltimore Washington

Glen Burnie, MD · View full profile →

Source Document

Official CMS Inspection Report (Medicare.gov)

Downloaded from CMS/Medicare.gov. Reflects what state inspectors documented and does not include the facility's plan of correction, which is submitted separately. Facilities may have taken corrective actions since this report was released.

Inspection Summary

AUTUMN LAKE HEALTHCARE AT BALTIMORE WASHINGTON in GLEN BURNIE, MD — inspection on October 30, 2025.

Found 1 citation. 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

FF0693

Quality of Life and Care Deficiencies

Potential for More Than Minimal Harm

Based on record reviews and interviews it was determined that the facility staff failed to ensure maintenance care was provided to a resident's tube feeding device.

This was evident for 1 (#8) of 1 resident reviewed for tube feedings.

The findings include:Percutaneous Endoscopic Gastrostomy (PEG) tube is a thin, flexible tube inserted into the stomach through a small incision in the abdominal wall. It provides a way to deliver nutrition and medications directly into the stomach when a person cannot eat or drink orally.During a review of complaint # 2599868 on 10/27/25 at 7:52 AM it was reported that flushes were not being completed daily on the PEG tube for Resident #8.During a review of medical records on 10/27/25 at 12:14 PM it was discovered that the Resident #8 had a PEG Tube placed on 7/25/25 and was in place upon his/her admission to the facility on 8/12/25.

During additional review of the orders for Resident #8 It was revealed that there were no orders placed for monitoring or flushing the PEG tube upon admission to the facility.

There were orders added for the PEG tube on 8/19/25 which stated to Flush with 5 - 10 milliliters Twice a day, an order to inspect surrounding skin of stoma/nares for redness/tenderness, swelling, irritation, purulent drainage, or signs of infection and an additional order to Complete tube site care and change syringe daily.

There was no documentation of the tube being flushed or monitored prior to the orders being added to the Medication Administration Record.

During an interview with Unit Manager #14 on 10/28/25 at 9:25 AM she reported she would expect orders for PEG tube care to be placed upon admission that would include monitoring the PEG site for infection and providing water flushes.

She reported Resident #8 was able to eat and drink by mouth and the PEG tube was not being used.

She confirmed water flushes would still be expected to be completed in residents that are not currently receiving tube feeding.

She reported she would have expected Resident #8 to have received the water flushes sooner than was ordered.During an interview with the Director of Nursing (DON) on 10/28/25 at 11:46 AM she reported she would expect Resident #8 to have had orders for flushing upon his/her admission because there's an order set that could be entered by the nursing staff.

The order set would have included monitoring the site of placement and providing maintenance flushing to the PEG tube.

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.

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Frequently Asked Questions

What is an F-tag violation?

F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.

Were these violations corrected?

Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.

How often do nursing home inspections happen?

CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.

What should families do about these violations?

Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in GLEN BURNIE, MD, (5) Report new concerns to state authorities.

Where can I see the full inspection report?

Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from AUTUMN LAKE HEALTHCARE AT BALTIMORE WASHINGTON or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.

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About This Inspection Report

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.