Public Record
Autumn Lake Healthcare at Pikesville
From CMS
Facility profile
- CMS overall rating
- 1 / 5
- Certified beds
- 140
- Avg. residents per day
- 113.8
*CMS Five-Star
*CMS
*CMS
Inspection record
On record from CMS
- Citations on record
- 97
- Inspections on file
- 6
- Last inspection
- 2025-06-18
*CMS
*CMS
*CMS
Citations
97 citations on record
Each deficiency cited on a CMS health inspection of this facility, sourced from the federal record. Open a report for the raw CMS Scope and Severity grade on each finding.
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
- 0880Generalpotential for harm
Provide and implement an infection prevention and control program.
- 0909Generalpotential for harm
Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
- 0925Generalpotential for harm
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
- 0561Generalpotential for harm
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
- 0582Generalpotential for harm
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
- 0584Generalpotential for harm
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.
- 0609Generalpotential for harm
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
- 0657Generalpotential for harm
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
- 0658Generalpotential for harm
Ensure services provided by the nursing facility meet professional standards of quality.
- 0842Generalpotential for harm
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
- 0918Generalpotential for harm
Have generator or other power source capable of supplying service within 10 seconds.
- 0741Generalpotential for harm
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
- 0541Generalpotential for harm
Install properly constructed and protected linen or trash chutes.
- 0511Generalpotential for harm
Have properly installed electrical wiring and gas equipment.
- 0100Generalpotential for harm
Meet other general requirements.
- 0211Generalpotential for harm
Keep aisles, corridors, and exits free of obstruction in case of emergency.
- 0223Generalpotential for harm
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
- 0293Generalpotential for harm
Have properly located and lighted "Exit" signs.
- 0353Generalpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0355Generalpotential for harm
Properly select, install, inspect, or maintain portable fire extinguishes.
- 0363Generalpotential for harm
Install corridor and hallway doors that block smoke.
- 0374Generalpotential for harm
Install smoke barrier doors that can resist smoke for at least 20 minutes.
- 0726Generalpotential for harm
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
- 0730Generalpotential for harm
Observe each nurse aide's job performance and give regular training.
- 0732Generalno actual harm
Post nurse staffing information every day.
- 0756Generalpotential for harm
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
- 0757Generalpotential for harm
Ensure each resident’s drug regimen must be free from unnecessary drugs.
- 0760Generalpotential for harm
Ensure that residents are free from significant medication errors.
- 0761Generalpotential for harm
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.
- 0770Generalpotential for harm
Provide timely, quality laboratory services/tests to meet the needs of residents.
- 0791Generalpotential for harm
Provide or obtain dental services for each resident.
- 0812Generalpotential for harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- 0825Generalpotential for harm
Provide or get specialized rehabilitative services as required for a resident.
- 0835Generalpotential for harm
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
- 0838Generalpotential for harm
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
- 0842Generalpotential for harm
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
- 0865Generalpotential for harm
Have a plan that describes the process for conducting QAPI and QAA activities.
- 0867Generalpotential for harm
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
- 0880Generalpotential for harm
Provide and implement an infection prevention and control program.
- 0883Generalpotential for harm
Develop and implement policies and procedures for flu and pneumonia vaccinations.
- 0886Generalpotential for harm
Perform COVID19 testing on residents and staff.
- 0887Generalpotential for harm
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
- 0908Generalpotential for harm
Keep all essential equipment working safely.
- 0919Generalpotential for harm
Make sure that a working call system is available in each resident's bathroom and bathing area.
- 0921Generalpotential for harm
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
- 0922Generalpotential for harm
Have enough backup water supply for essential areas of the nursing home.
- 0925Generalpotential for harm
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
- 0947Generalpotential for harm
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
- 0006Generalpotential for harm
Conduct risk assessment and an All-Hazards approach.
- 0550Generalpotential for harm
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
- 0558Generalpotential for harm
Reasonably accommodate the needs and preferences of each resident.
- 0570Generalpotential for harm
Assure the security of all personal funds of residents deposited with the facility.
- 0578Generalpotential for harm
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
- 0580Generalpotential for harm
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
- 0584Generalpotential for harm
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.
- 0607Generalpotential for harm
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
- 0623Generalpotential for harm
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
- 0624Generalpotential for harm
Prepare residents for a safe transfer or discharge from the nursing home.
- 0625Generalpotential for harm
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
- 0636Generalpotential for harm
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
- 0638Generalpotential for harm
Assure that each resident’s assessment is updated at least once every 3 months.
- 0641Generalpotential for harm
Ensure each resident receives an accurate assessment.
- 0655Generalpotential for harm
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
- 0656Generalpotential for harm
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- 0657Generalpotential for harm
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
- 0684Generalpotential for harm
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- 0688Generalpotential for harm
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
- 0689Seriousimmediate jeopardy
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- 0695Generalpotential for harm
Provide safe and appropriate respiratory care for a resident when needed.
- 0711Generalpotential for harm
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
- 0225Generalpotential for harm
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
- 0324Generalpotential for harm
Provide properly protected cooking facilities.
- 0347Generalpotential for harm
Properly provide smoke detection systems in areas open to corridors.
- 0353Generalpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0362Generalpotential for harm
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
- 0363Generalpotential for harm
Install corridor and hallway doors that block smoke.
- 0712Generalpotential for harm
Have simulated fire drills held at unexpected times.
- 0900Generalpotential for harm
Meet Health Care Facilities Code mechanical requirements.
- 0914Generalpotential for harm
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
- 0918Generalpotential for harm
Have generator or other power source capable of supplying service within 10 seconds.
- 0923Generalpotential for harm
Have proper medical gas storage and administration areas.
- 0036Generalpotential for harm
Establish emergency prep training and testing.
- 0037Generalpotential for harm
Establish staff and initial training requirements.
- 0039Generalpotential for harm
Conduct testing and exercise requirements.
- 0880Generalpotential for harm
Provide and implement an infection prevention and control program.
- 0812Generalpotential for harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- 0677Generalpotential for harm
Provide care and assistance to perform activities of daily living for any resident who is unable.
- 0558Generalpotential for harm
Reasonably accommodate the needs and preferences of each resident.
- 0200Generalpotential for harm
Meet other general requirements.
- 0223Generalpotential for harm
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
- 0321Generalpotential for harm
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- 0324Generalpotential for harm
Provide properly protected cooking facilities.
- 0353Generalpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0400Generalpotential for harm
Meet fire sprinkler requirement for tall buildings.
- 0541Generalpotential for harm
Install properly constructed and protected linen or trash chutes.
- 0712Generalpotential for harm
Have simulated fire drills held at unexpected times.
- 0918Generalpotential for harm
Have generator or other power source capable of supplying service within 10 seconds.
FAQ
Questions and answers
- What is Autumn Lake Healthcare at Pikesville?
- Autumn Lake Healthcare at Pikesville is a Medicare- and Medicaid-certified nursing home in Pikesville, MD, tracked by the Centers for Medicare & Medicaid Services (CMS). Its CMS Certification Number (CCN) is 215082.
- What is the CMS rating for Autumn Lake Healthcare at Pikesville?
- Autumn Lake Healthcare at Pikesville has a CMS overall rating of 1 out of 5 stars. CMS rates nursing homes on health inspections, staffing, and quality measures.
- How many beds does Autumn Lake Healthcare at Pikesville have?
- Autumn Lake Healthcare at Pikesville is certified for 140 beds. It serves an average of 113.8 residents per day.
- How many citations does Autumn Lake Healthcare at Pikesville have?
- Autumn Lake Healthcare at Pikesville has 97 citations on record from CMS health inspections, each tied to a federal deficiency tag.
- When was Autumn Lake Healthcare at Pikesville last inspected?
- Autumn Lake Healthcare at Pikesville was last inspected on June 18, 2025. CMS surveys nursing homes about once a year and after complaints.
- What can I do if I have concerns about care at this facility?
- Start by raising the concern with the facility administrator or director of nursing. Every state also runs a free long-term care ombudsman program that advocates for residents and families; the federal Eldercare Locator at eldercare.acl.gov can connect you with yours. Complaints about quality of care can also be filed with your state survey agency.
*Sourced from the Centers for Medicare & Medicaid Services (CMS). See the official record on CMS Care Compare. If you believe any information is inaccurate, report it here.
/nursing-home/215082-autumn-lake-healthcare-at-pikesville