Autumn Lake Healthcare At Bridgepark

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on complaint, reviews of a medical record, and staff interview, it was determined that the nursing staff failed to: 1) follow a physicians orders for withholding a cardiovascular medication when the pulse rate was less than 100 and document the resident's pulse rate when administering the cardiovascular medication, and 2) correctly document the route the cardiovascular medication should be administered. This was evident for 1 of 2 residents (Resident #1) reviewed during the complaint survey.The findings include:Review of Complaint 2662089 on 11/13/25 at 6:30 AM revealed a an allegation Resident #1 was not receiving quality of care at

the facility.Resident #1 was admitted to the facility on [DATE REDACTED] with diagnoses that include but not limited to being totally ventilator dependent, tracheostomy, and using a feeding tube for nutrition and hydration.

Resident #1 is totally dependent upon the nursing staff for all aspects of his/her care. Resident #1 was sent out to the hospital on [DATE REDACTED] for facial/head swelling.Review of Resident #1's medical record on 11/13/25 at 6:30 AM revealed a physician order, dated 09/05/25, instructing the nursing staff to administer the cardiovascular medication, Propranolol Hydrochloride, 10 milligrams, by mouth, every 8 hours, for tachycardia (a fast heart rate). Hold the medication if Resident #1's heart rate is less than 100 beats per minute.A review of Resident #1's September and October 2025 Medication Administration Records (MAR) revealed the nursing staff were signing off as administering a dose of Propranolol to Resident #1 without documenting Resident #1's heart rate and confirming Resident #1's heart rate was less than 100.The nursing staff also failed to correct the route in Resident #1's medical record as administering the Propranolol as being administered through Resident #1's gastrostomy tube (feeding tube).In an interview with the Director of Nursing (DON) on 11/13/25 at 9:30 AM, the DON was not aware the nursing staff were not documenting a pulse rate when administering the cardiovascular medication Propranolol to Resident #1 nor that the route of administering was by mouth.

Residents Affected - Some

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

11/13/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Autumn Lake Healthcare at Bridgepark

4017 Liberty Heights Avenue Baltimore, MD 21207

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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

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

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.

Based on observation during the initial tour of the facility on 11/13/2025 at 5:35 AM, it was determined that

the facility nursing staff failed to maintain the medication carts locked and secure. This was evident for 3 of 4 nursing units observed during a complaint survey.The findings include:During the initial tour of the facility

on 11/13/2025 at 5:35 AM, the second-floor nursing unit was observed with one medication cart unlocked.

Observations also include a medicine cup, located on top of the unlocked medication cart, with 2 cherry-colored oval tablets in the cup. The medication cart was unattended by any of the nursing staff.During an observation of the fourth-floor nursing unit on 11/13/2025 at 5:45 AM, the nurse surveyor observed 2 medication carts unlocked and unattended by any of the nursing staff.During an observation of

the third-floor nursing unit on 11/13/2025 at 5:55 AM, the nurse surveyor observed 2 medication carts unlocked and unattended by any of the nursing staff.

Event ID:

Facility ID:

If continuation sheet